Department of Veterans Affairs Medical Center Ann Arbor Michigan

ANN ARBOR, MI — Veterans who suffer cardiac arrest during a VA hospital stay are more likely to survive the experience than patients who have such events cardiac arrests in other U.S. hospitals. And, a year later, they are also more likely to still be alive.

Those are two of the findings from a study of in-hospital cardiac arrest at VA hospitals at the Ann Arbor, MI, VAMC. The research was presented at the American Heart Association/American Stroke Association 2017 Scientific Sessions and Resuscitation Science Symposium and published in Circulation.1

The study investigators analyzed data from all veterans who experienced an in-hospital cardiac arrest (IHCA) at any VA hospital between January 2013 and June 2015. A total of 5,252 patients suffered IHCA at 94 facilities.

At the VA hospitals, a median of 33.6% patients survived to discharge. Nationally, about 200,000 patients suffer in-hospital cardiac arrests, and 18-20% live until discharge, according to a study in the Journal of the American Heart Association.2

IHCA survival rates at VA hospitals ranged from 23.2% to 56.1%, with half of the hospitals posting rates between 30.1% and 36.5%. The national range demonstrated much greater variability, with individual hospital survival rates of 0% to 51.7%.

The researchers expressed surprise at the results. “Survival was not as bad as we expected. This encourages us that trying to care for these patients and setting up resuscitation systems in hospitals is worthwhile,” said co-author Brahmajee Nallamothu, MD, MPH, of the Ann Arbor VAMC. Nallamothu was also an author of an Institute of Medicine report issued two years ago on strategies to improve cardiac arrest survival.

A number of factors might contribute to the better performance of VA hospitals, he said. Difference in patients and in study methodology could account for some of that. The VA’s national focus on “ensuring high-quality education and certification for its providers through the Resuscitation Education Initiative (REdI)” likely also contributes to the more positive outcomes at VA hospitals, Nallamothu told U.S. Medicine.

Designed to increase the number of clinical and nonclinical staff who are certified to provide advanced cardiac life support (ACLS) and basic life support (BLS), the Resuscitation Education Initiative uses American Heart Association guidelines to train VA employees. REdI uses simulation-based training offered through the VA’s Simulation Learning Education and Research Network (SimLEARN).

While RedI might explain the better performance of VA hospitals compared to American hospitals overall, the researchers continue to study the data to gain a better understanding of the variation among VA hospitals.

“We didn’t have a chance in the preliminary work to examine individual hospital level features or micro-processes associated with resuscitation practices that explained this variation,” said Nallamothu. “We are now involved in understanding what types of hospitals and, even more importantly, what types of micro-processes these hospitals have put in place that may be associated with improved IHCA survival.”

One-year Survival

VA patients also appear to live one year post-discharge at somewhat higher rates than other patients. Among veterans at VA hospitals who had IHCA and survived to discharge, 63.6% were still alive one year later.

That’s significantly better than the national average. “When compared with other survivors of IHCA in non-VA hospitals, our findings are encouraging,” said Nallamothu. “In an analysis of Medicare beneficiaries with IHCA, we previously reported a one-year survival of 58.5%.”

The researchers also compared one-year survival rates of IHCA survivors to IHCA survival rates to discharge by VA hospital. “While substantial variation existed across hospitals in in-hospital survival,” the authors noted, “there was minimal variation in one-year survival.” Half of the VA hospitals had one-year post-IHCA survival rates between 63.2% and 64.1% and all 94 hospitals had rates between 61.6% and 66%.

The consistent results could be driven by the relatively small number of deaths at each facility Nallamothu said, explaining. “The challenge is that, with only a few cases, it is hard to know what a specific hospital’s mortality rate was. The low numbers at some facilities made it difficult from a statistical approach to tease out a signal of differences across hospitals versus random noise.

The unexpected finding of a “lack of correlation between long-term survival and in-hospital survival suggests that even after discharge these patients may need specific and tailored services to optimize outcomes,” he said.

Those tailored services might be most important in the immediate post-discharge period, based on a recent study by Emory University researchers in Atlanta who found IHCA survivors had nearly three times the risk of death in the first 90 days following discharge compared to matched controls who had not experienced IHCA. After three months, the increased risk of death for IHCA survivors was 2.19 times that of the controls, while the mortality rates after a year were comparable between the two groups.3

A patient’s destination on discharge also can provide critical information about services required and mortality risk. The Emory team compared one-year survival of IHCA patients to matched controls who were hospitalized during the same period and did not have cardiac arrest while in the hospital and found that patients in both groups had the same one-year survival rate of 82%, if discharged to home without services. Patients discharged to skilled nursing or rehabilitation services had slightly elevated risk of death compared to their matched cohort. Dramatic survival difference emerged among patients discharged to long-term hospital care, where IHCA survivors had four times the risk of death or hospice where they had 20 times the mortality risk of matched non-IHCA survivors.

The Ann Arbor VAMC continues to explore ways to improve outcomes for veterans who suffer in-hospital cardiac arrest. “IHCA is an important problem,” said Nallamothu. “We believe the VA is well-positioned to be a leader in developing solutions in this space for veterans and other patients.”

1Chakrabarti AK, Iwashyna T, Burns J, Saint S, Bradley S, Koboli P, Kamphuis L, Sales A, Nallamothu B. Abstract 17387: Hospital-Level Variation in Short Term and Long-Term Survival after In-Hospital Cardiac Arrest in the Veterans Health Administration. Circ. 2017;136:A17387.

2Merchant RM, Berg RA, Yang L, Becker LB, Groeneveld PW, Chan PS. Hospital Variation in Survival After In-hospital Cardiac Arrest. JAHA. 2014;3:e000400.

3Feingold P, Mina MJ, Burke RM, Hashimoto B, Gregg S, Martin GS, Leeper K, Buchman T. Long-term survival following in-hospital cardiac arrest: A matched cohort study. Resuscitation. 2016 Feb;99:72-8.