In-Hospital Cardiac Arrest: The Elephant in the Hospital Room

Code Blue. Every clinician dreads these two words — and with good reason: The urgency; The stakes; The unpredictability of emergency event care. But, most of all, they dread the high likelihood that their coding patient won’t survive.

In-hospital cardiac arrest (IHCA) claims hundreds of thousands of lives each year in the U.S. — including 75 percent of adults who experience it.^1,2 IHCA is one of the most significant contributors to overall mortality in hospitals, and its impact on patients, society, and the healthcare system as a whole is difficult to overstate.

Yet improving IHCA outcomes seems to be a relatively low priority — perhaps because it’s most often the result of some other deadly condition rather than a primary cause of death. But research shows that specific process improvements and consistent implementation of best practices could prevent many IHCA deaths.^3-6

So why, then, do poor outcomes persist? Why isn’t there a more concerted effort to address this glaring “elephant in the room”? And how can organizations and responders optimize Code Blue performance to get IHCA survival rates moving in the right direction? Keep reading to find out.

A persistent problem,

hiding in plain sight

Sizing up the impact of in-hospital cardiac arrest

IHCA differs from out-of-hospital cardiac arrest (OHCA) in that IHCA patients are typically being treated for a known condition when the Code Blue occurs. This makes IHCA treatment more complex — but if resuscitation can be achieved, clinicians can continue treating that underlying condition to help extend quantity and quality of life.

Unfortunately, a patient’s overall chances of surviving to discharge after IHCA in the U.S. are well below 50 percent, and adult outcomes are particularly troubling (data published prior to COVID-19).^1,2

Plus, mortality isn’t the only concern. IHCA patients who do survive often develop a neurologic injury, myocardial dysfunction, reperfusion injury, or other serious conditions associated with post-cardiac arrest syndrome.

At the very least, these conditions typically require extended hospitalization or hospital readmission, putting even more strain on patients, caregivers, communities, clinicians, and hospital systems. And in the worst-case scenario, these conditions may ultimately result in death.

We know hospitals can do better because many already are

In 2015, the Institute of Medicine (now the National Academy of Medicine) raised the alarm about “unacceptably low” survival rates and quality of life following cardiac arrest.³ They termed these stats “unacceptable” in part due to enormous variability between communities and hospitals that suggests improvement is achievable — and that disparities in care rather than innate complexities of IHCA result in poorer outcomes.

In fact, some providers are more than four times as likely to successfully resuscitate IHCA patients, even after adjusting for age and other comorbidities.^3-5

Hardest hit by these disparities are minorities, low-income patients, and those working night and weekend shifts.^3,5,7 To address this issue, the Academy urges hospitals, among other action items, to implement best practices used by higher performing health systems. And they aren’t alone in this recommendation.

Poor outcomes defy decades of advocacy

For more than 20 years, the American Heart Association (AHA) has been pushing for improvements in Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC). In 1999, they formed the National Registry of Cardiopulmonary Resuscitation (NRCPR), which has since become the Get with the Guidelines®-Resuscitation (GWTG-R) program. This powerful registry initiative:

• Collects and analyzes CPR data from hospitals across the U.S.
• Publishes evidence-based guidelines for inpatient CPR and ECC
• Provides participating hospitals with ongoing resources, training, and benchmarking capabilities to help improve outcomes over time

In fact, a 2018 study showed that increased duration of GWTG-R participation is associated with improved quality of IHCA care.⁸ But this program and others like it are voluntary, and relatively few hospitals are currently participating. 

Additionally, the AHA set a goal in 2010 of increasing the average adult IHCA survival rate to 35 percent. Considering some hospitals are already performing at this level, the AHA stands by its assertion that this goal is achievable. 

Yet we’re still falling well short of that goal nationally — and what improvements we have seen since in the last decade have been very limited, with survival increasing only two percent overall.^2,6

4 key gaps impacting IHCA performance

1.  Awareness & attention

In general, cardiac arrest receives far less attention — and funding⁹ — than:

• Other high-risk cardiovascular conditions, such as stroke and myocardial infarction⁸
• Out-of-hospital cardiac arrest, which is not much more prevalent than IHCA and should be considered and treated differently
• Other scenarios that result in preventable harm or death

This lack of attention primarily stems from a lack of awareness — not only of the prevalence, poor outcomes, and overall impact of IHCA but also of the process adjustments and best practices that could improve those outcomes. It is entirely possible that the goal of preventing cardiac arrest has overshadowed the need to optimize clinical performance when it occurs.

2. Data & research

Perhaps the largest factor impacting IHCA outcomes is the lack of data clinicians and hospitals need to standardize, implement, and reinforce best practices. 

• There is no centralized, national registry or consistent reporting requirement for IHCA data in the U.S.
• The data we do have is voluntarily reported, so not necessarily representative of or applicable to the full population.
• IHCA data collection is still paper-based in most hospitals, relying on inconsistent, error-prone, manual processes.
• Data is typically uploaded as a flat PDF, which is not searchable and makes analysis and reporting extremely difficult.

Furthermore, the number of gold-standard clinical trials focused on IHCA research is limited. So in short, we are missing every type of high-quality, comprehensive data that could support desperately needed improvements in IHCA treatment.

3. Innovation

Current Code Blue equipment, systems, and processes are likely limiting clinicians’ ability and opportunities to improve IHCA care. Unlike so many other areas of the hospital, there have been few advancements and innovations in this critical area. 

Today, most Code Blue responders are doing their best to optimize IHCA outcomes despite:

• Outdated crash cart designs that fail to address known risks
• Manual, paper-based resource management, event documentation, reporting, and data analysis processes
• Interventions based on individual team experience and tribal knowledge rather than easily accessible, industry best practices

4. Risk mitigation

Many “risk points” can impact clinical performance throughout the Code Blue process. Responders and hospitals should consider the following to help mitigate risks before, during, and after each event.

• Before: 
  • Do our Code Blue response teams have adequate, ongoing training?
  • Are crash carts properly prepped, checked, and stocked at all times?

• During:
  • Is the team using proven best practices for every intervention?
  • Can responders access necessary medication, supplies, and equipment quickly, easily, and reliably?

• After:
  • Are response teams regrouping immediately after emergency events for “hot debriefs” to analyze quantitative quality indicators and continually optimize performance?
  • Is the organization regularly aggregating and reviewing IHCA data via detailed “cold debriefs” to improve system-wide outcomes over time?