Hospital Variation in Time to Defibrillation After In-Hospital Cardiac Arrest
Hospital Variation in Time to Defibrillation After In-Hospital Cardiac Arrest
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DOI：
10.1001/archinternmed.2009.196
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发表时间：
2009-07-27
影响因子：
--
通讯作者：
Nallamothu, Brahmajee K.
中科院分区：
文献类型：
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作者：
Chan, Paul S.;Nichol, Graham;Nallamothu, Brahmajee K.
背景资料：延迟除颤与院内心脏骤停后的生存率降低相关，但医院在除颤响应时间上的差异程度以及延迟除颤的医院预测因素仍然未知。使用分层模型，我们评估了延迟除颤率的医院差异，（>2分钟）及其对国家心肺复苏登记处内200家医院的7479名心脏骤停成人住院患者生存率的影响。结果：调整后的除颤延迟率在医院之间差异很大（范围为2.4%-50.9%），在调整患者因素后，医院水平的影响占除颤延迟总变化的很大一部分。我们发现，在随机选择的医院中，具有相同协变量的患者获得延迟除颤的几率比另一家医院高46%。然而，在传统的医院评估因素中，（参考类别：≥ 500张床：OR，0.74 [ 95% CI，0.53-1.04]）和心脏骤停位置（参考类别：重症监护室;遥测室：OR，1.92 [95%CI，1.65-2.22];非监护室：OR，1.90 [95%CI，1.61-2.24]）与延迟除颤率的差异相关。调整后的出院存活率也存在很大差异（范围，5.3%-49.6%），除颤时间表现最好的四分位数医院的生存率较高（与下四分位数相比：上四分位数的OR为1.41 [95%CI，1.11-1.77]）。延迟除颤的发生率在不同医院之间差异很大，但在很大程度上无法用传统的医院因素来解释。考虑到其与提高生存率的关系，需要进一步研究以更好地了解顶级医院提供除颤的最佳实践。
Background: Delays to defibrillation are associated with worse survival after in-hospital cardiac arrest, but the degree to which hospitals vary in defibrillation response times and hospital predictors of delays remain unknown.Methods: Using hierarchical models, we evaluated hospital variation in rates of delayed defibrillation (>2 minutes) and its impact on survival among 7479 adult inpatients with cardiac arrests at 200 hospitals within the National Registry of Cardiopulmonary Resuscitation.Results: Adjusted rates of delayed defibrillation varied substantially among hospitals (range, 2.4%-50.9%), with hospital-level effects accounting for a significant amount of the total variation in defibrillation delays after adjusting for patient factors. We found a 46% greater odds of patients with identical covariates getting delayed defibrillation at one randomly selected hospital compared with another. Among traditional hospital factors evaluated, however, only bed volume (reference category: = 500 beds: OR, 0.74 [ 95% CI, 0.53-1.04]) and arrest location (reference category: intensive care unit; telemetry unit: OR, 1.92 [95% CI, 1.65-2.22]; nonmonitored unit: OR, 1.90 [95% CI, 1.61-2.24]) were associated with differences in rates of delayed defibrillation. Wide variation also existed in adjusted hospital rates of survival to discharge (range, 5.3%-49.6%), with higher survival among hospitals in the top-performing quartile for defibrillation time (compared with the bottom quartile: OR for top quartile, 1.41 [95% CI, 1.11-1.77]).Conclusions: Rates of delayed defibrillation vary widely among hospitals but are largely unexplained by traditional hospital factors. Given its association with improved survival, future research is needed to better understand best practices in the delivery of defibrillation at top-performing hospitals.