1. Is Participation in Get With the Guidelines-Resuscitation Program Associated with Improved Quality of Cardiac Arrest Care? Monique L. Anderson, MD, Graham Nichol, MD; David Dai, Ph.D; Paul S. Chan, MD, MSc; Steven Bradley, MD; Sana M. Al-Khatib, MD, MHS; Eric D. Peterson, MD, MPH for the AHA GWTG Investigators

2. All Rights Reserved, Duke Medicine 2007 M.L. Anderson: None G. Nichol: Research Grant- Minor; Contract from Philips Healthcare Inc. Andover MA for study of US during resuscitation (PI); Contract from Velomedix Inc. Menlo Park CA for pilot study of hypothermia in patients with STEMI (National co PI, waived personal compensation); Contracts from Cardiac Science Corp., Waukesha, WI; HeartSine Technologies Inc., Newtown, PA; Philips Healthcare Inc.; Physio-Control Inc., Redmond WA and ZOLL Inc., Chelmsford MA for Dynamic AED Registry (PI). D. Dai: None P.S. Chan: None S. Bradley: None S.M. Al-Khatib: None E.D. Peterson: PI of the AHA GWTG data analysis center Disclosures

3. All Rights Reserved, Duke Medicine 2007 Background Large geographic variations in outcomes after sudden cardiac arrest. Certain care processes are associated with improved outcome after in-hospital cardiac arrest: –Monitored or Witnessed Events 1 –Time to Defibrillation 2 –Endotracheal tube confirmation 3 GWTG- Resuscitation is a national quality improvement program for in-hospital cardiac arrest It is unknown whether duration of hospital participation in GWTG-R is associated with improved quality of care. 1 Brady, W. J., K. K. Gurka, et al. (2011). "In-hospital cardiac arrest: impact of monitoring and witnessed event on patient survival and neurologic status at hospital discharge." Resuscitation 82(7): 845-852. 2 Chan, P. S., H. M. Krumholz, et al. (2008). "Delayed time to defibrillation after in-hospital cardiac arrest." N Engl J Med 358(1): 9-17. 3Phelan, M. P., J. P. Ornato, et al. (2013). "Appropriate documentation of confirmation of endotracheal tube position and relationship to patient outcome from in-hospital cardiac arrest." Resuscitation 84(1): 31-36.

4. All Rights Reserved, Duke Medicine 2007 To determine if ongoing participation in GWTG-R is associated with greater adherence to quality measures. To create an in-hospital cardiac arrest composite quality score and determine whether hospital composite performance has improved overtime. To determine types of hospitals deriving benefit from participation in GWTG-R. Aims

5. All Rights Reserved, Duke Medicine 2007 6 quality measures based on strength of evidence, clinical relevance, and/or magnitude of relationship between quality measure and outcome: –Device Confirmation of Correct Endotracheal Tube Placement –Monitored and/or Witnessed Event –Time to First Compressions <= 1 min –Time to First Shock <= 2 min for pulseless VT/VF –Time to IV/IO Epinephrine/Vasopressin ≤ 5 min –Subsequent Shock Delivered >= 2 min after previous shock Composite measure score: –Opportunity based score encompassing 6 quality measures –total # care processes correctly performed in eligible patients total # of care opportunities among eligible patients Quality Measures

6. All Rights Reserved, Duke Medicine 2007 Study Population –Adults ≥ 18 yrs of age, index cardiac arrest –Location in ICU or inpatient wards –Hospitals Participation > 1 yr >5 cardiac arrests per yr –Jan 1, 2000 until Dec 31, 2012 Multivariable Logistic Regression with GEE –To create the composite score –To determine independent effect of time in GWTG-R –To determine if programs benefit equally from participation (Interaction testing) Statistical Analysis

7. All Rights Reserved, Duke Medicine 2007 Baseline Characteristics of Study Population

8. All Rights Reserved, Duke Medicine 2007 Baseline Characteristics of Study Population

9. All Rights Reserved, Duke Medicine 2007 Hospital Characteristics

10. All Rights Reserved, Duke Medicine 2007 Change in Individual Measures Δ +35.8 Δ +7.1Δ +4.8 Δ -2.7 Δ +8.1 Δ +35.6 p<0.001, except time to defib p=0.369

11. All Rights Reserved, Duke Medicine 2007 Change in Composite Measure Over Time Δ 13.1; p<0.001

12. All Rights Reserved, Duke Medicine 2007 Impact of Time in GWTG-R on Composite Score Odd Ratio95% CI Time in GWTG (per yr of participation)1.151.14-1.16 Adjusted for Time in GWTG-R + Patient and Hospital Characteristics 1 1.141.13-1.15 Adjusted for Time in GWTG-R + Patient and Hospital Characteristics 1 + calendar time 1.041.02-1.06 1 Adjusted for patient characteristics-age, sex, race, pre-existing conditions (diabetes, abnormal electrolytes, MI, CHF, hepatic Insufficiency, arrhythmia, pneumonia, HIV, AIDS, cancer, renal insufficiency, asystole/PEA, sepsis, respiratory insufficiency, prior MI, prior CHF, acute stroke, arrest at night, arrest on weekends, location of arrest, illness category (medicine vs surgery); Interventions in Place at Time of Arrest (Vascular Access, PA catheter, Arterial Catheter, Hemodialysis, IABP, or mechanical ventilation. Hospital Characteristics- nurse to bed ratio, hospital ownership, geographic region, cardiac surgery capability, hospital bedside, rural vs urban, trauma services, teaching hospital, percentage of ICU beds.

13. All Rights Reserved, Duke Medicine 2007 Impact of time in GWTG-R on Composite Performance by Hospital Types

14. All Rights Reserved, Duke Medicine 2007 Program participation is voluntary; study findings may not be applicable to hospitals that choose not to participate. Eligibility for a particular measure may have been limited by data collection. Quality and composite score might be lower (e.g. endotracheal tube confirmation). Despite this, clear trends in improvement of adherence to measures over time. Limitations

15. All Rights Reserved, Duke Medicine 2007 Duration of hospital participation in GWTG-R is associated with improved quality of care over time. While there is evidence of overall improvement, there are still areas where care has not improved: e.g. time to first defibrillation shock for pulseless VF/VT patients. Improvements in resuscitation quality of care observed among most hospital types – Rural hospitals may need more attention in GWTG-R to derive benefit – Larger hospitals derive greater benefit from participation over time compared to smaller hospitals Future work will examine relationship between composite adherence and in-hospital outcomes of cardiac arrest. Summary

16. All Rights Reserved, Duke Medicine 2007 Acknowledgements Eric D. Peterson, MD, MPH Graham Nichol, MD, MPH David Dai, Ph.D. Paul S. Chan, MD, MSc Steven Bradley, MD Sana M. Al-Khatib, MD, MHS GWTG- R Investigators

17. All Rights Reserved, Duke Medicine 2007 Additional Slides

18. All Rights Reserved, Duke Medicine 2007 Distribution of Hospital Composite Measure Scores

19. All Rights Reserved, Duke Medicine 2007 Example Eligibility Criteria VT/VF <= 2 min Denominator 1.All patients who were pulseless when need for chest compressions and/or defibrillation arose 2.First documented rhythm is pulseless VF/VT 3.Exclusions: 1.Date/Time for chest compressions or defibrillations not provided 2.Patient did not have documented VF/VT 3.Advanced Directive in Place 4.ROSC before 2 min Numerator 1.Time to first shock less than or equal to 2 minutes.

20. All Rights Reserved, Duke Medicine 2007 Eligible Measures for Study Composite Score Variables – Monitored and/or Witnessed Event – Time to First Compressions <= 1 min – Time to First Shock <= 2 min for VT/VF – Time to IV/IO Epinephrine/Vasopressin – Subsequent Shock Delivered >= 2 min after previous shock – Device Confirmation of Correct Endotracheal Tube Placement Not Included – Time to first assisted ventilation <= 1 min – Chest compressions provided – Defibrillation shock provided for pulseless VF/VT – Shock energy (360J for monophasic/>=120 J for biphasic

21. All Rights Reserved, Duke Medicine 2007 Baseline Duration Determination