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

• Published in: The American heart journal 2017-11, Vol.193, p.108-116
• Main Authors: Fendler, Timothy J., Spertus, John A., Kennedy, Kevin F., Chan, Paul S.
• Format: Article
• Language: English
• Subjects: Aged; Cardiac arrest; Cardiopulmonary resuscitation; CPR; Data collection; Female; Follow-Up Studies; Guidelines; Heart; Heart Arrest - complications; Heart Arrest - mortality; Heart Arrest - therapy; Heart diseases; Hospital Mortality - trends; Hospitals; Hospitals - statistics & numerical data; Humans; Incidence; Intensive care; Male; Median (statistics); Medical prognosis; Middle Aged; Mortality; Nervous System Diseases - epidemiology; Nervous System Diseases - etiology; Patients; Prognosis; Resuscitation; Resuscitation Orders; Retrospective Studies; Right to die; Risk; Risk Assessment; Risk Factors; Stroke; Survival; Survival Rate - trends; Time Factors; United States - epidemiology
• ISSN: 0002-8703; 1097-6744
• DOI: 10.1016/j.ahj.2017.05.017

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. 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. 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). 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.