By Geoffrey Lighthall, MD, PhD
Cardiac arrests in adult in-hospital patients increased during the past two decades in the United States. While survival after in-hospital cardiac arrests steadily increased from approximately 15% in 2000 to 25% in 2017,1 lower survival rates of in-hospital cardiac arrests during nights and weekends in both adult and pediatric populations occurred.
Over the course of the past five years, my colleagues and I have hosted clinical leaders from several U.S. Veterans Affairs’ (VA) hospitals for code team training courses. These courses resulted from earlier efforts to breakdown the key functions of cardiac arrest management into teachable modules for different aspects of code team function such as:
- defibrillator expertise
- CPR and basic life support
- advance decision making
- system analysis
Through our interaction with peers, it was abundantly clear there was huge variation in code team composition – especially between day and night teams. Further, about half of the groups we met with had a wish list of professions they hoped to include on their teams. This led to our interest in conducting a survey among VA hospitals to more formally document the variability in team composition in hospitals and any diurnal variation occurring within hospitals.
Our study in the November 2022 issue of The Joint Commission Journal on Quality and Patient Safety (JQPS) evaluated variations of personnel attending to codes based on day/night/weekend conditions within VA hospitals, as well as variations of personnel responsible for intubations during codes.
We surveyed hospital leaders regarding code team membership, leadership and intubations during four time periods (weekday daytime, weekday nighttime, weekend daytime and weekend nighttime). More than 90 eligible VA hospitals responded, and findings showed:
- Code teams were significantly smaller during “off-hours”.
- Membership in code teams during regular vs. off-hours was significantly greater for ICU physicians, anesthesiologists and pharmacists.
- Significant differences were found for codes led by ICU attendings and intubations performed by ICU attendings.
- ICU-based physicians were team leaders more often in high-complexity hospitals, while hospitalists led the majority in low-complexity hospitals.
- ICU physicians had significantly less involvement in code intubations in low-complexity hospitals, while respiratory therapists took on most of this responsibility in low-complexity hospitals and particularly at night.
Our findings propose that systems such as ours – where the patient composition is largely the same throughout – may learn a great deal about best practices regarding resuscitation by a more comprehensive analysis of all arrests, including patient, hospital and institutional factors such as code team composition, as well as training activities and efforts to identify and stabilize deteriorating patients.
System-wide participation in registries such as the American Heart Association's (AHA) Get with the Guidelines® registry could help collect further in-depth data, as well as the creation of a VA specific registry. Either way, we believe that every cardiac arrest carries important data that should be sought, recorded and analyzed rather than being lost in the cloud of 'business as usual.'
1Benjamin EJ, et al. Heart disease and stroke statistics—2018 update: a report from the American Heart Association. Circulation. 2018 Mar 20;137:e67–e492.
Geoffrey Lighthall, MD, PhD, is a Professor in the Department of Anesthesiology, Pain and Perioperative Medicine at the Palo Alto VA Medical Center and Stanford University School of Medicine in California. His clinical focus areas are in anesthesia, critical care medicine, and cardiac and thoracic anesthesia.