ResCU II: Improving In-hospital Cardiac Arrest Care and Discovering Keys to Super-Survivorship

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Project Background: Since at least VHA Directive 2008-063, improving in-hospital cardiac arrest (IHCA) care has been an important VA priority. This focus was renewed after the Office of the Inspector General report on IHCA in 2013 (13-00054-148), and repeated again in 2015 with the formation of VHA Resuscitation Quality Improvement Committee (RQI-C) by Assistant Deputy Undersecretary for Health for Clinical Operations. At the individual level, vast amounts of VA clinician time are devoted to having every clinician recertify their Basic or Advanced Cardiac Life Support training every two years to improve the care of IHCA. Our previous ResCU-1 project identified critical gaps in VA care of IHCA: (1) documentation of key IHCA factors that help systems drive quality improvement, and clinicians determine prognosis and treatment after IHCA were often unavailable; (2) 1/3rd to 2/3rd of VA hospitals underutilized other best practices in IHCA care, e.g. mock codes and post-IHCA debriefing. Yet, ResCU-1 also found (3) some Veterans had remarkable recovery from IHCA, becoming “super-survivors”—but we do not know how the care of super-survivors differed. Specific Aims: Building on ResCU-1's foundations and in partnership with the VA Resuscitation Education Initiative (REdI), we will: A1. Assess implementation of a new documentation template as a model for quality efforts. A2. Develop & pilot new interventions to improve IHCA care, focusing on post-code debriefing, mock code simulation training, and code documentation. A3. Identify IHCA super-survivors & `best practices' associated with their care. Project Methods: Aim 1 will be accomplished by retrospective review of all IHCA hospitalizations' electronic medical records, research-assistant annotation of those records, and multi-level statistical modeling. Aim 2 will use video-site-visits to identify barriers and facilitators using established frameworks (CFIR and TDF), and then partner to pilot and implement interventions (likely beginning with virtual learning collaborative) to improve documentation, mock codes, and post-IHCA debriefing. Aim 3 will do deep semi- structured interviews with super-survivors, their informal caregivers and control patients of similar disability who did not recover after IHCA, and their VA clinicians to identify candidate practices that may contribute to super-survivorship. The association of those practices with super-survivorship will then be tested in a prospective cohort of IHCA survivors. All will be integrated to produce and disseminate with partners a `Code Blue Survivor Bundle' to form the basis of further improvements in VA care of IHCA. Anticipated Impact on Veteran's Healthcare: An in-hospital cardiac arrest occurs when a patient's heart stops beating effectively, either due to electrical or muscular problems. IHCA is a medical emergency; VA devotes great resources to responding to IHCAs. In VA HSR&D's ResCU-1 study, we discovered that important improvements can be made to the care of many Veterans who suffer IHCA. In this proposed ResCU- 2 study, we will partner with VA national efforts to improve these fundamentals. In Aim 1, we will evaluate efforts to improve documentation, and identify where documentation remains inadequate. In Aim 2, we will identify barriers and facilitators to improving IHCA care via better documentation, better practice and better post-IHCA debriefing—and design interventions to improve their use. But ResCU-1 also showed that a few Veterans go on from IHCA to become super-survivors, showing remarkable recovery after their cardiac arrest. In Aim 3, we will use mixed methods to discover practices that lead to super-survivorship, and disseminate the secrets to such excellent care throughout VA.