Abstract 05: Hospital Variation In Epinephrine Administration Prior To Defibrillation For Cardiac Arrest Due To Shockable Rhythm

Abstract

Background: Contrary to guidelines, we recently found that epinephrine administration before first defibrillation for in-hospital cardiac arrest (IHCA) due to a shockable rhythm is not uncommon. However, the extent to which the above practice varies across hospitals and its association with hospital-level survival is unknown. Methods: Using 2000-19 data from the Get With The Guidelines ® -Resuscitation (GWTG-R) registry, we identified 57,816 adult patients (521 sites) with an index IHCA due to an initial shockable rhythm who received at least 1 defibrillation prior to achieving return of spontaneous circulation. We constructed multivariable hierarchical regression models to examine site-level variation in epinephrine before first defibrillation and its association with hospital survival. Results: Overall, the median rate of epinephrine before defibrillation was 18.8% and varied markedly across hospitals (range: 0%-70.6%, median odds ratio [OR] 1.50; 95% C.I. 1.43 - 1.57). Compared to hospitals in the lowest quartile (Q1) for epinephrine before defibrillation, hospitals in the highest quartile (Q4) were more likely to be major teaching hospitals and have more hospital beds. After adjusting for baseline variables, the median risk-standardized survival was 42.5% (IQR: 39.2%-46.0%). Compared to Q1 hospitals (epinephrine first rate of 0-12.4%), there was a stepwise decline in risk-standardized survival at hospitals with higher rates of epinephrine before first defibrillation: Q2: RR 0.95 [0.90-0.99]; Q3: RR 0.91 [0.87-0.96]; Q4: RR 0.81 [0.77-0.86]; P value for trend <0.001. Conclusions: For patients with shockable IHCA, there is marked hospital variation in epinephrine administration prior to first defibrillation, and this practice is associated with lower rates of survival to discharge. Hospital efforts to prioritize immediate defibrillation for patients with shockable IHCA are urgently needed.

Adrenaline in Resuscitation for Shockable Rhythms: Are We Barking the Wrong Tree?*

“…The study by Stewart et al (6) deepens knowledge gained from several previous articles on registry data that have shown that deviations from ACLS guidelines are pervasive.…”

“…In this issue of Critical Care Medicine , Stewart et al (6) analyze data of an observational cohort of 37,668 adult patients with an IHCA due to an initial shockable rhythm from 513 U.S. hospitals included in Get With The Guidelines-Resuscitation (GWTG-R) registry during a 20-year period (2000–2019). In the study, they try to determine hospital variation rates in adrenaline administration before defibrillation and its association with IHCA risk-adjusted survival.…”

“…The current article by Stewart et al (6) addresses a crucial topic, drawing data from a 20-year span of the GWTG-R registry, encompassing over 37,000 patients. The well-executed study, employing a thoughtful statistical approach, reveals a shocking level of noncompliance with guidelines, particularly in larger teaching hospitals.…”

“…Perhaps we need to take a step back and return to basics, addressing the fundamental question posed by the study by Stewart et al (6): What factors contribute to the notably low adherence to basic guidelines, and what proactive measures can be implemented to mitigate this issue? The substantial variation among hospitals emphasizes the opportunity to reshape established care patterns and enhance the management of patients experiencing shockable IHCA, a subgroup with the highest potential for survival.…”