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Observational Study
. 2017 Nov:193:108-116.
doi: 10.1016/j.ahj.2017.05.017. Epub 2017 Aug 7.

Association between hospital rates of early Do-Not-Resuscitate orders and favorable neurological survival among survivors of inhospital cardiac arrest

Timothy J Fendler  1 , John A Spertus  2 , Kevin F Kennedy  3 , Paul S Chan  4 ; American Heart Association's Get With the Guidelines-Resuscitation Investigators  5
Affiliations
Observational Study

Association between hospital rates of early Do-Not-Resuscitate orders and favorable neurological survival among survivors of inhospital cardiac arrest

Timothy J Fendler et al. Am Heart J. 2017 Nov.

Abstract

Background: Current guidelines recommend deferring prognostication for 48 to 72 hours after resuscitation from inhospital cardiac arrest. It is unknown whether hospitals vary in making patients who survive an arrest Do-Not-Resuscitate (DNR) early after resuscitation and whether a hospital's rate of early DNR is associated with its rate of favorable neurological survival.

Methods: Within Get With the Guidelines-Resuscitation, we identified 24,899 patients from 236 hospitals who achieved return of spontaneous circulation (ROSC) after inhospital cardiac arrest between 2006 and 2012. Hierarchical models were constructed to derive risk-adjusted hospital rates of DNR status adoption ≤12 hours after ROSC and risk-standardized rates of favorable neurological survival (without severe disability; Cerebral Performance Category ≤2). The association between hospitals' rates of early DNR and favorable neurological survival was evaluated using correlation statistics.

Results: Of 236 hospitals, 61.7% were academic, 83% had ≥200 beds, and 94% were urban. Overall, 5577 (22.4%) patients were made DNR ≤12 hours after ROSC. Risk-adjusted hospital rates of early DNR varied widely (7.1%-40.5%, median: 22.7% [IQR: 19.3%-26.1%]; median OR of 1.48). Significant hospital variation existed in risk-standardized rates of favorable neurological survival (3.5%-44.8%, median: 25.3% [IQR: 20.2%-29.4%]; median OR 1.72). Hospitals' risk-adjusted rates of early DNR were inversely correlated with their risk-standardized rates of favorable neurological survival (r=-0.179, P=.006).

Conclusions: Despite current guideline recommendations, many patients with inhospital cardiac arrest are made DNR within 12 hours after ROSC, and hospitals vary widely in rates of early DNR. Higher hospital rates of early DNR were associated with worse meaningful survival outcomes.

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Figures

Figure 1
Figure 1. Patient Cohort Exclusion Flow Chart
ROSC, return of spontaneous circulation; DNR, do not resuscitate; ED, emergency department; OR, operating room; CPC, Cerebral Performance Category
Figure 2
Figure 2. Distribution of Early DNR Status Adoption Rates, Across Hospitals
Hospital rates for early DNR status adoption, both, (A) unadjusted, and (B) after multivariable adjustment for demographics, comorbidities, and event characteristics. (DNR, do not resuscitate; IQR, interquartile range)
Figure 3
Figure 3. Association of Early DNR Status Adoption with Favorable Neurological Survival, Across Hospitals
Correlation between hospital rates of favorable neurological survival (adjusted for CASPRI score) and hospital rates of early DNR status adoption, both (A) unadjusted, and (B) after multivariable adjustment for demographics, comorbidities, and event characteristics. (DNR, do not resuscitate; CASPRI, Cardiac Arrest Survival Post-Resuscitation In-hospital)
See this image and copyright information in PMC

References

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