In-Hospital Cardiac Arrest

A cardiac arrest is classified as ‘in-hospital’ (IHCA) if it occurs in a hospitalized patient who had a pulse at the time of admission. Unfortunately, the majority of patients resuscitated successfully from IHCA die before hospital discharge, and their prognosis has changed little over the past 30 years. Recent data indicate that survival to hospital discharge after in-hospital cardiac arrest is approximately 20%. A variety of factors have been proposed as determinants of poor outcomes associated with IHCA, which include first monitored rhythm, time to first shock, duration of cardiac arrest, hospital location of cardiac arrest and time of day of cardiac arrest occurrence. According to current guidelines for prevention of in-hospital cardiac arrest, hospitals should provide a system of care that includes staff education for rapid response, appropriate and regular patient vital sign monitoring, clear and uniform system of timely calling for assistance. Finally, after cardiac arrest has occurred, the quality of resuscitation and early defibrillation are crucial factors for improving survival.

the actionable steps organizations should take to successfully reduce in-hospital cardiac arrests and summarizes the available evidence-based practice protocols. This document is revised annually and is always available free of charge on our website.

Leadership Checklist
Use this checklist as a guide to determine whether current evidence-based guidelines are being followed in your organization: Involve key stakeholders, including patients and family members, in improvement work.
Involve those on the frontline in identifying hospital units that are 'poor' locations for a code (e.g., MRI due to strict protocols related to the magnet, office settings due to potential for patients to not be immediately identifiable). Understand why these locations are deemed as poor locations for a code.
Involve the organization's Patient and Family Advisory Council (PFAC) in improvement efforts. Involve those who may benefit from observation (e.g., students, quality improvement specialists, etc) in the code response itself.
Assess cardiorespiratory/cardiopulmonary assessment and treatment skills on an ongoing basis. Use mock scenarios and simulation for educational purposes.
Consider additional education beyond biennial completion of the standard basic life support courses to improve resuscitation performance, with emphasis on high quality CPR. See Appendix A and Appendix B.
Improve the ease with which patients and family members can activate the rapid response team. Implement a consistent, inclusive patient and family education program to explain how, why, and when to activate a rapid response team. Consider offering patients and family members CPR training. See Education for Patients and Family Members.
Review events preceding a cardiac arrest with those on the frontline to identify potential for future prevention.

Anticipate process barriers early.
Set up simulation training and mock scenarios to identify process barriers. Outline the 'picture perfect' room for an emergency response (e.g., what are all of the tools/resources needed in that scenario?).
Select representative users and representative environments for device usability testing (e.g., don't choose only experts for usability testing) (Karsh & Scanlon, 2007).
Build a clear plan when there is a shortage of supplies or personnel (e.g., medication shortages or product replacements). Identify where these resources exist in the organization when one unit is at maximum capacity and ensure these resources are flexible to accommodate (e.g., personnel from other units understand their roles when having to cover in other areas of the organization).
Indicate crash cart readiness visually (e.g., note with green visual tags which crash carts are 'ready to go' and note with red tags which crash carts need to be 'reassembled or sterilized'). Consider standardizing who is restocking crash carts and when instead of restocking as needed on the units.
Establish a feedback loop to the hospital operator to ensure the operator understands what teams are available to deploy.
Standardize the hospital's triage system to admit patients to the appropriate level of care according to their clinical condition and severity.

Standardize protocols and expectations.
Create a culture where everyone feels empowered to call for help at the earliest indication. See Rapid Response Teams APSS. It might be beneficial to include a lowrisk 'phone a friend' model where less experienced personnel can get a quick opinion before activating a Rapid Response Team.
Establish a Resuscitation Outcomes Steering Committee (ROSC). See Appendix C for more information.
Clarify cardiac arrest safety guidelines specific to the location (e.g., MRI safety rules). Include an established score, like the National Early Warning Score 2, in the medical chart to detect variations in clinical condition of the patient.
Ensure that cardiac arrest and rapid response protocols are embedded into clinical workflows, whether electronic or paper. Clarify who on the emergency response team will remove all non-code team members from the area upon arrest.
Ensure adequate training and documentation of resuscitation competencies and skills. Standardize expectations for communication. See Hand-Off Communication APSS. Strengthen efforts for post-resuscitation care to improve survival upon discharge after an in-hospital cardiac arrest (Girotra et al., 2020).
Standardize a response team member responsible for minimizing distractions to the team member doing chest compressions.
Apply medication safety principles in emergency response environments and ensure protocols are the same throughout the organization to minimize the cognitive load during high-stress situations.
Designate a group responsible for stocking the crash carts in the standardized way and establish a clear line of communication with this group if changes are made to equipment, supplies, etc (ASA, n.d.).
Expect that all team members involved in a code will debrief after each code. Follow guidelines for infection prevention (ISRRS, 2020).

Sustain improvements.
Measure and report number of arrest-related deaths by the total number of admissions monthly.
Ensure there are enough staff to effectively manage necessary preventive care. Ensure that leaders have a simple process to oversee rapid response and resuscitation improvement work while also considering how it aligns with other initiatives across the organization.
Consider upgrading communication systems to relieve communication burden between operator and code team members during urgent situations.
Provide feedback to manufacturers about ease of device use. Communicate all changes multiple times in multiple ways and determine if formal education is needed around the change.
Debrief on a regular basis to solicit team feedback about barriers to sustained compliance. Adjust the plan quickly and nimbly as needed.
Hold staff accountable for providing the standard of care and reward success.

Clinical Workflow
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Education for Patients and Family Members
Care team members should: • Explain to patients and family members why the patient may be at an increased risk for cardiac arrest. • Indicate what to watch out for that may indicate deterioration.
• Outline exactly what to do, who to call, and how to report if they notice patient deterioration. • Describe the basic components of resuscitation, such as activation of the rapid response team and CPR. • Explain what will happen after they've made the report of potential deterioration and the family members' roles once the emergency response is called • Explain that is family members are removed from the room during an emergency response, a professional from the organization will be assigned to provide them with ongoing updates.
Patients and family members should understand the significant value they hold to the care team in watching out for signs of potential cardiac arrest. Patients and family members can: • Watch for significant changes in vital signs

Performance Improvement Plan
Follow this checklist if the leadership team has determined that a performance improvement project is necessary: Gather the right project team. Bee sure to involve the right people on the team. You'll want two teams: an oversight team that is broad in scope, has 10-15 members, and includes the executive sponsor to validate outcomes, remove barriers, and facilitate spread. The actual project team consists of 5-7 representatives who are most impacted by the process. Whether a discipline should be on the advisory team or the project team depends upon the needs of the organization. Patients and family members should be involved in all improvement projects, as there are many ways they can contribute to safer care.

RECOMMENDED IN-HOSPITAL CARDIAC ARREST IMPROVEMENT TEAM
• Admitting and registration staff Understand what is currently happening and why. Reviewing objective data and trends is a good place to start to understand the current state, and teams should spend a good amount of time analyzing data (and validating the sources), but the most important action here is to go to the point of care and observe. Even if team members work in the area daily, examining existing processes from every angle is generally an eye-opening experience. The team should ask questions of the Create a process map once the workflows are well understood that illustrates each step and the best practice gaps the team has identified (IHI, 2015). Brainstorm with the advisory team to understand why the gaps exist, using whichever root cause analysis tool your organization is accustomed to (IHI, 2019). Review the map with the advisory team and invite the frontline to validate accuracy.

Complete this Lean Improvement Activity:
Conduct a SIPOC analysisto understand the current state and scope of the problem. A SIPOC is a lean improvement tool that helps leaders to carefully consider everyone who may be touched by a process, and therefore, should have input on future process design.
frontline during the observations that allow them to understand each step in the process and identify the people, supplies, or other resources needed to improve patient outcomes.
Image 2: Example process map. Click here to expand.
Prioritize the gaps to be addressed and develop an action plan. Consider the cost effectiveness, time, potential outcomes, and realistic possibilities of each gap identified. Determine which are a priority for the organization to focus on. Be sure that the advisory team supports moving forward with the project plan so they can continue to remove barriers. Design an experiment to be trialed in one small area for a short period of time and create an action plan for implementation.
Image 3: Example process map with gaps. Click here to expand.  It is important to be nimble and move quickly to keep team momentum going, and so that people can see the results of their labor. At the same time, don't move so quickly that you don't consider the larger, organizational ramifications of a change in your plan. Be sure to have a good understanding of the other, similar improvement projects that are taking place so that your efforts are not duplicated or inefficient.

IN-HOSPITAL CARDIAC ARREST METRICS TO CONSIDER ASSESSING
• Total number of arrest-related deaths/total number of admissions (defined as a patient receiving arrest resuscitative efforts (either CPR or defibrillation) at any time during admission who does not survive to hospital discharge) • Time to first chest compression within one minute

What We Know About In-Hospital Cardiac Arrest
Cardiac arrest is defined as the sudden cessation of cardiac activity resulting in unresponsiveness of the patient, accompanied by a cease of normal breathing and circulation (Patel, 2020). An intervention to resuscitate the patient is required within moments to prevent significant harm or death. The longer the patient is without effective intervention, the greater the risk for cognitive and physical deterioration (Mędrzycka-Dąbrowska et al., 2018). Therefore, the outcomes of the patient are largely dependent on the preparedness of the hospital before the event even occurs. Studies show that preparedness of a rapid response team is associated with a 15% reduction in mortality (Rocha et al., 2018).
The majority of patients demonstrate signs and symptoms of instability and deterioration 6-8 before arrest occurs (Mezzaroba et al., 2016). These symptoms commonly include desaturation and hypotension.

Risk Factors
• Older age • Poor functional status prior to arrest • Those with sepsis • Those with pneumonia • Those with hypotension • Those with renal and hepatic dysfunction • Those not on an appropriate unit (e.g. a surgery patient on a medical floor).

Clinical Implications
In US adults alone, there are an estimated 290,000 cases of in-hospital cardiac arrests each year (Andersen, 2019).
In many cases, in-hospital cardiac arrest is a major preventable cause of patient morbidity and mortality. It is estimated that between 17% (Peberdy et al., 2003) and 24% (Go et al., 2013) of inhospital cardiac arrest patients survive to hospital discharge. For those patients who do survive to discharge, nearly 25% will be newly placed in a skilled nursing facility and many will likely suffer brain injury, injury to the nervous system, or other complications (Peberdy et al., 2003).

Resources
Resources for In-Hospital Cardiac Arrest Improvement: • AHA: Get with the Guidelines It has been suggested that the rates of survival to discharge post-in-hospital cardiac arrest are lower for black patients (25.2%) than for white patients (37.4%) (Chan, 2009).
In-hospital cardiac arrest etiology is distinguished by cardiac and noncardiac. Most in-hospital adult cardiac arrest events are related to cardiac complications, including, but not limited to, arrhythmias, myocardial infarction, or heart failure (50-60% of cases) (Andersen 2019). The second most common etiology is non-cardiac, or respiratory insufficiency (15-40% of cases) (Andersen 2019). Most pediatric cardiac arrests are commonly preceded by respiratory compromise (Duff et al., 2019).
Cardiac arrest at night and lack of a witness are significant causes for mortality in in-hospital cardiac arrest patients (Chon et al., 2013).
If possible, it is important to understand the patient's code status before initiating CPR but do not let this cause a delay in initiation. DNR status should be clearly communicated in multiple ways, including, but not limited to, armbands, room signs, and flagging the chart. Consider the possibility that notation of status via armbands may cause the information on the armband to be outdated if there is a patient change and a delay in replacement of the armband. The bedside nurse should know the status prior to calling the Rapid Response Team (RRT). The RRT should not do anything until they speak to the bedside nurse, regardless of code status. If there is no provider order in the chart, the patient is automatically a full code.