Impact of resuscitation system errors on survival from in-hospital cardiac arrest☆

Początek formularza

• Joseph P. Ornato, Mary Ann Peberdy, Renee D. Reid, V. Ramana Feeser, Harinder S. Dhindsa

• for the NRCPR Investigators

Dół formularza

Received 14 May 2011; received in revised form 9 September 2011; accepted 11 September 2011. published online 28 September 2011. http://www.resuscitationjournal.com/article/S0300-9572(11)00539-9/fulltext

Article Outline

1. Abstract

2. 1. Introduction

3. 2. Methods

1. 2.1. Data collection and integrity

2. 2.2. Study outcomes

3. 2.3. Inclusion/exclusion criteria

4. 2.4. Categorization and counting of resuscitation system error types

5. 2.5. Statistical analysis

2. 3. Results

3. 4. Discussion

1. 4.1. Limitations

2. 4.2. Public health importance

2. 5. Conclusions

3. Conflict of interest statement

4. Funding sources

5. Acknowledgement

6. Appendix A. 

7. Appendix B. Supplementary data

8. References

9. Copyright

Abstract 

Background

An estimated 350,000-750,000 adult, in-hospital cardiac arrest (IHCA) events occur annually in the United States. The impact of resuscitation system errors on survival during IHCA resuscitation has not been evaluated. The purpose of this paper was to evaluate the impact of resuscitation system errors on survival to hospital discharge after IHCA.

Methods and results

We evaluated subjective and objective errors in 118,387 consecutive, adult, index IHCA cases entered into the Get with the Guidelines National Registry of Cardiopulmonary Resuscitation database from January 1, 2000 through August 26, 2008. Cox regression analysis was used to determine the relationship between reported resuscitation system errors and other important clinical variables and the hazard ratio for death prior to hospital discharge. Of the 108,636 patients whose initial IHCA rhythm was recorded, resuscitation system errors were committed in 9,894/24,467 (40.4%) of those with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) and in 22,599/84,169 (26.8%) of those with non-VF/pVT. The most frequent system errors related to delay in medication administration (>5
min time from event recognition to first dose of a vasoconstrictor), defibrillation, airway management, and chest compression performance errors. The presence of documented resuscitation system errors on an IHCA event was associated with decreased rates of return of spontaneous circulation, survival to 24
h, and survival to hospital discharge. The relative risk of death prior to hospital discharge based on hazard ratio analysis was 9.9% (95% CI 7.8, 12.0) more likely for patients whose initial documented rhythm was non-VF/pVT when resuscitation system errors were reported compared to when no errors were reported. It was 34.2% (95% CI 29.5, 39.1) more likely for those with VF/pVT.

Conclusions

The presence of resuscitation system errors that are evident from review of the resuscitation record is associated with decreased survival from IHCA in adults. Hospitals should target the training of first responders and code team personnel to emphasize the importance of early defibrillation, early use of vasoconstrictor medication, and compliance with ACLS protocols.

Keywords: Inhospital, Resuscitation, Quality, Outcomes, Errors

 

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1. Introduction 

The Institutes of Medicine (IOM) landmark publication (“To Err is Human”) estimated that at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors.¹ Although the magnitude of the problem has been questioned,² the Canadian Adverse Events (AE) Study confirms an alarming frequency of in-hospital AEs (7.5 per 100 hospital admissions; 95% confidence interval [CI], 5.7-9.3), 36.9% (95% CI, 32.0-41.8%) of which are potentially preventable. Death occurred in 20.8% (95% CI, 7.8-33.8%) of cases.

The American Heart Association (AHA) Get with the Guidelines National Registry of Cardiopulmonary Resuscitation (NRCPR) collects data on adult and pediatric in-hospital cardiac arrest (IHCA) events from approximately 10% of hospitals in the United States.³ From this registry, NRCPR investigators have documented lower survival from adult in-hospital cardiac arrest (1) on nights and weekends likely due, at least in part, to system factors,³ (2) when defibrillation is delayed greater than 2
min in patients whose initial IHCA rhythm is ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT),⁴ and (3) in certain hospital locations.⁵

The purpose of this paper was to determine whether the presence of resuscitation system errors reported to NRCPR are associated with lower likelihood of survival in adult patients who experience an IHCA.

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2. Methods 

2.1. Data collection and integrity 

NRCPR is a prospective, observational, multi-center performance improvement registry of IHCA events. Hospitals join voluntarily and pay an annual fee for data support and report generation.

Hospital medical records on sequential IHCA events are abstracted by trained, NRCPR-certified, performance improvement personnel at each participating institution. All data elements have standardized definitions allowing aggregate data analysis from multiple sites, and all data transfer is in compliance with the Health Insurance Portability and Accountability Act. Oversight for operations is provided by the American Heart Association, a scientific advisory board, and an executive database steering committee.

Multiple efforts are taken to assure data integrity, including data abstractor certification prior to allowing data entry, over 300 software checks and smart skips to assist with accurate data entry, and ongoing abstractor training with monthly user's group calls and an annual user's group conference. Even though the most challenging data points to collect during resuscitation are event times and intervals, these are documented in a high percentage of cases in NRCPR hospitals. For example, in this analysis the time intervals from IHCA onset to start of CPR and first vasopressor administration were captured in 89% and 76%, respectively. Further details of the NRCPR database and data integrity can be found in previous publications.⁶, ⁷

2.2. Study outcomes 

The primary study outcome was survival to hospital discharge. Secondary outcomes were return of spontaneous circulation (ROSC) and survival for 24
h after IHCA.

2.3. Inclusion/exclusion criteria 

The current analysis includes all consecutive, adult (age ≥18
years), initial, pulseless IHCA events entered from 549 different hospitals from January 1, 2000 through August 26, 2008. All adults (≥18
years of age) who experienced an in-hospital resuscitation event and who had documentation of initial heart rhythm were eligible for inclusion. An event is defined as: (1) cardiopulmonary arrest requiring chest compressions and/or defibrillation, or (2) acute respiratory compromise requiring emergency assisted ventilation leading to cardiopulmonary arrest requiring chest compressions and/or defibrillation. All events must also elicit a resuscitation response by facility personnel and have a resuscitation record completed. Events are excluded if the arrest begins outside of the hospital, is limited to a shock delivered by an implanted cardioverter-defibrillator (ICD), or occurs on a patient with a pre-existing do not attempt resuscitation order. For patients having multiple IHCA events during the same hospitalization, only the first event was analyzed.

2.4. Categorization and counting of resuscitation system error types 

The NRCPR database contains a section for the data abstractor at each hospital site to capture “self-reported” system errors that were noted during or following the resuscitation effort on the code record and/or hospital chart or to document errors reported by resuscitation members. Types of error categories included alerting hospital-wide resuscitation response, airway management, vascular access, chest compression, defibrillation, medications, leadership, protocol deviation, and equipment function issues, with specific subcategories listed in Table 1. Each type of individual error had a checkbox that was to be filled in by the data abstractor if supported by the code record and/or hospital chart documentation, or conveyed by personnel on scene. For analysis of this data, one point was assigned for each individual error box checked on a given IHCA event. We totaled the number of cases with individual system errors and created subtotals for the various types of errors to calculate the number of cases in which any error occurred and to catalogue and quantify the specific types of errors that occurred.

Table 1. Distribution of resuscitation system errors.

Error category	N	% of cases	% of reported resuscitation system errors
Alerting
Delay in alerting code team	232	0.2	1.1
Pager issue	66	0.1
Other	266	0.2
Airway
Aspiration related to provision of airway	225	0.2	17.0
Airway insertion delay	2672	2.3
Delayed recognition of airway misplacement	328	0.3
Intubation attempted, not achieved	319	0.3
Multiple intubation attempts	3314	2.8
Other	1939	1.6
Vascular access
Delay in obtaining access	846	0.7	3.4
Inadvertent arterial cannulation	37	<0.1
Infiltration or inadvertent disconnection of IV line	415	0.4
Other	480	0.4
Chest compression
Compression rate of ∼100/min not maintained	2530	2.1	7.2
Interruption of compressions >10 s at any time	177	0.1
Delay in starting chest compressions	155	0.1
No board used beneath patient during compressions	758	0.6
Other	120	0.1
Defibrillation
Defibrillation delay >2 min from event recognition in patients with an initial CA rhythm of VF/pVT due to insufficient trained personnel or defibrillator not immediately available	6364	5.4	19.0
Energy level too high/low based on AHA guidelines	485	0.4
Incorrect defibrillator paddle/pad placement	32	<0.1
Defibrillator malfunction	131	0.1
Shock given, not indicated	957	0.8
Shock indicated, not given	607	0.5
Other	1068	0.9
Medications
First vasopressor (epinephrine or vasopressin) delay >5 min from event recognition in cases with event duration >5 min	20,035	16.9	42.5
Wrong route of administration	202	0.2
Wrong dosage	575	0.5
Wrong medication selection	1190	1.0
Code team leadership
Delay in identifying team leader	276	0.2	2.8
Knowledge of equipment	107	0.1
Knowledge of medications/protocols	539	0.5
Knowledge of team member roles	223	0.2
Code team oversight	196	0.2
Too many individuals present in room	105	0.1
Protocol deviation from AHA Guidelines
Deviation from AHA ACLS guideline  recommendations	1521	1.3	3.1
Other	84	0.1
Equipment issues
Availability	1100	0.9	3.9
Malfunction	540	0.5
Other	387	0.3

We counted and added one point on each case for each NRCPR “process of care exception” error defined as: (1) delay of >5
min from IHCA event recognition to the first dose of a vasoconstrictor (epinephrine or vasopressin) on events that had a duration of >5
min; or (2) delay of >2
min from IHCA event recognition to the first defibrillation shock in patients whose initial documented IHCA rhythm was VF/pVT. “Resuscitation system errors” were defined as the total number of reported system errors plus the number of “process of care exceptions” in each case. When the process of care exception matched a self reported error (e.g., delay in time to first shock, time to first vasoconstrictor administration), only one point was assigned for the error to avoid double counting.

2.5. Statistical analysis 

All data analyses were performed using PASW Statistics version 17.0.2 (SPSS, Inc., Chicago, IL). Chi square and 95% confidence intervals were used for comparison of descriptive variables. ANOVA using Scheffe's test for multiple comparisons was used to analyze the relationship between 0, 1, 2, 3 or more errors and outcome variables. Cox regression analysis was used to determine the relationship between reported resuscitation system errors as well as other important clinical variables and the hazard ratio for death prior to hospital discharge. The status of the primary outcome (i.e., life or death) was ascertained at three time points following resuscitation: (1) whether ROSC occurred; (2) 24
h following the IHCA event; and (3) at hospital discharge. Cox regression analysis was also used to determine the hazard ratio for the time of day (day/evening or 7a-11p vs. night or 11p-7a) and day of week (weekday or M-F, weekend or S-Su) on the reporting of resuscitation system errors during a IHCA event.

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3. Results 

A total of 118,387 in-hospital, adult, index IHCA cases were entered into the NRCPR database from January 1, 2000 through August 26, 2008. Of these, 84,440 (71.3%) had no system errors recorded and 33,947 (28.7%) had one or more system errors recorded. Of the cases with system errors, 26,919 (22.7%) had 1 error, 5614 (4.7%) had 2 system errors, and 1414 (1.2%) had 3 or more system errors. Of all cases in which the initial rhythm was recorded, 84,169/108,636 (77.5%) had non VF/pVT and 24,467/108,636 (22.5%) had VF/pVT. Errors were committed in 22,599/84,169 (26.8%) of non VF/pVT, and in 9894/24,467 (40.4%) of those with VF/pVT as the first documented rhythm.

The distribution of system errors for all IHCA patients by category is noted in Table 1. The most frequent system errors related to delay in medication administration (>5
min time from event recognition to first dose of a vasoconstrictor), defibrillation, airway management, and chest compression performance errors. The 5.4% of cases having a delay in defibrillation of >2
min represents the percentage of patients with defibrillation delays using all patients as the denominator including those without initial shock-able rhythms. There were 6364 patients with defibrillation delays of >2
min out of 20,125 patients with an initial shock-able rhythm documented, yielding a delay in defibrillation in 31.6% of patients in whom defibrillation was indicated.

Table 2 displays the demographic characteristics of IHCA events with and without reported resuscitation system errors. Cases in which system errors were documented were more likely to be male, not witnessed/monitored at the time of arrest, during the night (11p-7a), on weekends (S-Su), initially in VF/pVT, medical (vs. surgical or cardiac) type admissions, or non-ICU patients (vs. ICU, ED, or OR/PACU patients) than cases in which no system errors were documented.

Table 2. Demographic characteristics of in-hospital CA events with and without resuscitation system errors.

	No resuscitation system errors	Resuscitation system errors	p
N (total = 118,387)	84,440 (71.3%)	33,947 (28.7%)	-
Age [mean, 95% CI]	66.07 [65.96, 66.18]	66.36 [66.20, 66.53]	.008
Male	48,428/84,440 (57.4%)	19,951/33,947 (58.8%)	.0001
Witnessed or monitored arrest	69,361/70,152 (98.9%)	25,729/26,636 (96.6%)	.0001
Initial documented CA rhythm VF/pVT	14,573/76,143 (19.1%)	9894/32,493 (30.4%)	.0001
Patient type
Cardiac	29,329/81,750 (35.9%)	11,487/33,757 (34.0%)	.0001
Medical	34,777/81,750 (42.5%)	15,483/33,757 (45.9%)
Surgical	17,644/81,750 (21.6%)	6787/33,757 (20.1%)
CA event location
ICU or stepdown/telemetry area	50,951/77,057 (66.1%)	17,692/31,707 (55.8%)	.0001
Non-ICU inpatient area	14,539/77,057 (18.9%)	9838/31,707 (31.0%)
Emergency department	9339/77,057 (12.1%)	3491/31,707 (11.0%)
Operating room or PACU	2228/77,057 (2.9%)	685/31,707 (2.2%)
Time of day
Day-evening (7a-11p)	54,888/80,480 (68.2%)	22,387/33,777 (66.3%)	.0001
Night (11p-7a)	25,592/80,480 (31.8%)	11,390/33,777 (33.7%)
Day of week
Weekday (M-F)	56,783/81,970 (69.3%)	23,236/10.711 (68.4%)	.003
Weekend (S-Su)	25,187/81,970 (30.7%)	10,711/33,947 (31.6%)

Resuscitation system errors occurred in the highest percentage of IHCA events in non-ICU inpatient areas (9838/24,378, 40.4%); they were least frequently noted on IHCA events occurring in ICU/stepdown units (17,692/69,643, 25.8%), EDs (3491/12,830, 27.2%), or Operating Room/Post-Anesthesia Care Units (685/2913, 23.5%) (p
=
.0001).

The presence of documented resuscitation system errors on an IHCA event was associated with decreased rates of ROSC, survival to 24
h, and survival to hospital discharge (Fig. 1) in all patients as a group and in those whose initial documented IHCA rhythm was separated into VF/pVT or non-VF/pVT categories. Characteristics that increased the likelihood of death prior to hospital discharge in patients whose initial rhythm was non-VF/pVT included: male gender, when the event occurred at night or on a weekend, or when there were documented resuscitation system errors (Fig. 2). There was a lower likelihood of death prior to hospital discharge if the event was witnessed or monitored, if the type of patient was cardiac or surgical (as opposed to general medical), and if the patient location was OR/PACU.

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• Fig. 1. 

Effect of any resuscitation system errors on an IHCA event and the rate of ROSC, survival for 24
h, and survival to hospital discharge for all patients and those with an initial documented IHCA rhythm of non-VF/pVT and VF/pVT.

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• Fig. 2. 

Association between the number of resuscitation system errors during an IHCA event and a significantly increased hazard ratio for death prior to hospital discharge stratified by patients with an initial IHCA rhythm of non-VF/pVT or VF/pVT.

Characteristics that increased the likelihood of death prior to hospital discharge in patients whose initial rhythm was VF/pVT included: when the event occurred at night or on a weekend, or when there were documented resuscitation system errors (Fig. 2). There was a lower likelihood of death prior to hospital discharge if the type of patient was cardiac or surgical (as opposed to general medical) or if the patient location was ED. The relative risk of death prior to hospital discharge based on hazard ratio analysis was 9.9% (95% CI 7.8, 12.0) more likely for patients whose initial documented rhythm was non-VF/pVT when resuscitation system errors were reported compared to when no errors were reported. It was 34.2% (95% CI 29.5, 39.1) more likely for those with VF/pVT.

Only certain types of resuscitation system errors were associated with an increased hazard ratio for death prior to hospital discharge. For patients whose initial rhythm was non-VF/pVT, delays in obtaining vascular access (i.e., an intravenous line) and medication errors increased the hazard ratio for death prior to hospital discharge (Fig. 3). For patients whose initial rhythm was VF/pVT, defibrillation problems and medication errors increased the hazard ratio for death prior to hospital discharge.

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• Fig. 3. 

Association between various types of resuscitation system errors and the hazard ratio for death prior to hospital discharge in patients whose initial IHCA rhythm was non-VF/pVT and VF/pVT.

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4. Discussion 

The principal finding in this study is that the presence of resuscitation system errors is associated with decreased survival from IHCA in adults. More errors were noted in patients whose initial documented IHCA rhythm was VF/pVT as opposed to those with non-shock-able rhythms. This finding is particularly relevant clinically, given that the majority of survivors of IHCA are those with initial VF/pVT.³

Our findings, although much broader, support those reported by Chan et al.⁴ who evaluated 6789 sequential patients with VF as the first documented rhythm in the NRCPR database and found that 30.1% of this cohort underwent defibrillation more than 2
min after initial recognition of their IHCA. Patients with delayed defibrillation had a significantly lower likelihood of ROSC (adjusted odds ratio, 0.55; 95% CI, 0.49-0.62; p
<
0.001) and survival at 24
h after the cardiac arrest (adjusted odds ratio, 0.52; 95% CI, 0.46-0.58; p
<
0.001). The Chan study was the first large scale analysis of data in IHCA patients identifying a specific defibrillation delay time cut-off (2
min or less after event recognition) that negatively impacts survival. Our analysis, in a larger sample size from the same registry, confirms that defibrillation system errors, including a >2
min delay from IHCA recognition to initial defibrillation accounts for higher mortality in the initial VF/pVT group, but it also found an association between medication errors and a lower likelihood of survival.

Peberdy et al.³ found that survival to discharge following in-hospital cardiac arrest is lower during nights (14.7% [95% CI, 14.3-15.1%] vs. 19.8% [95% CI, 19.5-20.1%]) or weekends (20.6% [95% CI, 20.3-21%] vs. 17.4% [95% CI, 16.8-18%]) compared with day/evening or weekdays, even after accounting for many potentially confounding IHCA event and hospital factors. Our current study confirms that nights and weekends are associated with an increased hazard ratio for death prior to hospital discharge in patients regardless of the initial documented IHCA rhythm and goes a step beyond the previously reported data in demonstrating an increased hazard ratio for death during those times in which there is an increase in resuscitation system errors, thus suggesting a link between increased error on nights and weekends and decreased survival during those times.

Kayser et al.,⁵ demonstrated that ED location was an independent predictor of improved survival, speculating that this was due to both the requirement for ED staff to receive basic and the advanced cardiac life support training, and their frequent experience in performing resuscitation compared to clinicians working on general hospital floors. Our paper supports this hypothesis by confirming that IHCA events occurring in the ED have a relatively low percentage of cases with resuscitation system errors.

Not all types of errors were associated with an increased hazard ratio for death prior to hospital discharge in our study. Olasveengen et al.,¹⁷ randomized out-of-hospital cardiac arrest patients to receive ACLS treatment with and without intravenous drug administration and determined that survival to discharge was the same in both groups. However, they were not able to identify the timeframe in which the drug therapy was given in the group that received an intravenous line and medication. In our IHCA population, we were able to demonstrate decreased survival when the first vasoconstrictor was administered >5
min after IHCA onset in patients whose arrest lasted for at least 5
min. The difference in our findings is likely due to the fact that the time from event onset to first drug administration is usually much shorter in- vs. out-of-hospital. In our study, the mean time from event onset to first epinephrine was 2.4 (95% CI, 2.3, 2.4)
min. In contrast, the time interval from collapse to first epinephrine in standard vs. high dose epinephrine pre-hospital trials is approximately 20
min.¹⁸

Much of the focus on patient safety and error prevention in hospitals focuses on interventions that relate to patient interactions that are of higher volume and lower acuity compared to resuscitation. In our study, the impact of resuscitation team errors on survival varied widely by both error type and the initial documented heart rhythm, with some errors causing little or no impact and others being associated with a significantly lower survival, particularly in the group of patients with initial VF/pVT. Given that resuscitation practices need to occur consistently well throughout all areas of the hospital and that responders will always have varying degrees of expertise and experience, our findings suggest that resuscitation training should be targeted to emphasize avoiding the types of errors having the greatest impact on survival (e.g., delays in initial defibrillation and medication administration and adherence to ACLS protocols).

An increasing body of evidence indicates that effective leadership and team work rather than just individual knowledge, skills, and attitudes are required to optimize outcomes and minimize errors in a variety of medical emergencies.⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵,¹⁶ Specific behaviors have been identified that contribute to effective leadership including providing orienting remarks, inviting team member contributions, promoting exchange of information and clear communication, and avoiding performing physical tasks that can be assigned to others during the emergency.⁸ In addition, there are four teamwork behavior principles that can help to avoid medical errors: (1) the leader should voice specific findings rather than diagnosing the problem prematurely; (2) all members of the team should “think out loud” and “talk to the room” as the case unfolds; (3) the leader should direct period reviews of quantitative information (e.g., drug dose, time, response); and (4) all members of the team should double-check crucial data.⁸

Unfortunately, the majority of these leadership and team behaviors could not be measured in this study. This is the likely explanation for why we were unable to demonstrate an association with reported “poor team leadership” and survival in our study. The definition of “good team leadership” is subjective and may not be reported consistently among institutions or that that magnitude of the effect on survival of other resuscitation errors drowns out the impact of poor team leadership.

Our observations confirm the association between the presence of resuscitation system errors that are evident from review of the resuscitation record and decreased survival from IHCA in adults. However, they do not point to a specific solution to the problem.

A number of recent simulator-based studies have identified qualitatively and quantitatively similar problems to those noted during clinical resuscitation.⁴, ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴ Team training can improve performance during simulation of medical emergencies,²⁵,²⁶, ²⁷, ²⁸ but not all training is equal or effective.¹², ¹³, ¹⁴ Siassakos et al.,¹², ¹³, ¹⁴ have identified specific elements required to improve outcome, including multi-professional training of all healthcare providers who manage an emergency in a realistic simulation setting. These elements need to be incorporated into team and leadership training, which are now recommended in the 2010 American Heart Association Guidelines for Adult and Pediatric Advanced Cardiovascular Life Support.²⁹, ³⁰

4.1. Limitations 

General limitations of NRCPR include: (1) registry hospitals may not be representative of all hospitals; (2) there is no on-site validation of data collection; (3) and there is no follow-up after hospital discharge. In addition, although medication use is tracked, NRCPR does not attempt to assess clinical eligibility for each medication. These limitations are similar to those of other contemporary in-hospital registries.

The specific limitation pertinent to this analysis is that NRCPR data is self-reported by having a trained abstractor review hospital charts and code records. The Get with the Guidelines NRCPR is a voluntary data collection/analysis quality improvement project. Participating hospitals pay a fee to the American Heart Association to have the data analyzed, benchmarked, and reported back to them quarterly. With hundreds of hospitals involved throughout the entire United States and very minimal hospital user fees, it has not been feasible to provide independent data validation at the hospital level.

The abstractors work with uniform definitions and uniform methods of data acquisition. The abstractors review the physician and nurse narrative notes in the hospital chart and the “code record” on each event. Thus, all of the errors identified came from a review of documentation in the patient charts. The abstractors do not capture whether the errors were “recognized” in the narrative notes by the doctors and nurses running the code or are evident from the documentation of events themselves (which is the case for the majority of errors that we looked at).

There is no way for the abstractor to verify whether errors may have occurred but were not documented. This may have resulted in an under-reporting of resuscitation team errors. If this occurred, if anything, it would increase the potential importance of our findings. Finally, we cannot exclude the possibility that individuals completing the code sheets could have checked off more “error boxes” in patients who did not achieve ROSC than the boxes they would have checked had the patient been resuscitated.

4.2. Public health importance 

The public health importance of these findings is considerable. Eisenberg and Mengert,³¹ estimated that there are 350,000-750,000 adult, IHCA events per year in the United States. Eliminating resuscitation system errors has the potential to save 21,000-44,000 additional lives per year in the United States from IHCA. This figure is ten times larger than the estimated 2000-4000 additional lives saved per year from out-of-hospital cardiac arrest that drove widespread deployment of public access defibrillation programs throughout the country.¹³

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5. Conclusions 

We conclude that the presence of resuscitation system errors that are evident from review of the resuscitation record is associated with decreased survival from IHCA in adults. Hospitals should target their training of first responders and code team personnel to emphasize the importance of early defibrillation when indicated, early use of vasoconstrictor medication, and compliance with established AHA ACLS resuscitation protocols.

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Conflict of interest statement 

None of the authors have any relevant conflicts.

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Funding sources 

None.

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Acknowledgement 

None.

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Appendix A. 

Get with the Guidelines - National Registry of Cardiopulmonary Resuscitation (NRCPR) investigators:

Mary E. Mancini, Robert A. Berg, Emilie Allen, Elizabeth A. Hunt, Vinay M. Nadkarni, Scott Braithwaite, Graham Nichol, Kathy Duncan, Tanya Lane Truitt, Melinda Smyth, Brian Eigel, Paul S. Chan, Tim Mader, Karl B. Kern, Sam Warren, Thomas Noel, Romergryko Geocadin, Dana Edelson, Vince Mosesso and Comilla Sasson.

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Appendix B. Supplementary data 

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