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Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Template for In-Hospital Cardiac Arrest
A Consensus Report From a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia)
Utstein-style reporting templates provide a structured framework with which to compare systems of care for cardiac arrest. The 2004 Utstein reporting template encompassed both out-of-hospital and in-hospital cardiac arrest. A 2015 update of the Utstein template focused on out-of-hospital cardiac arrest, which makes this update of the in-hospital template timely. Representatives of the International Liaison Committee on Resuscitation developed an updated in-hospital Utstein reporting template iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018. Data elements were grouped by hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. Elements were classified as core or supplemental by use of a modified Delphi process. Variables were described as core if they were considered essential. Core variables should enable reasonable comparisons between systems and are considered essential for quality improvement programs. Together with core variables, supplementary variables are considered useful for research.
The first Utstein-style guideline for the reporting of data from cardiac arrest was published in 1991 and represented the output from an international multidisciplinary meeting held at the Utstein Abbey near Stavanger, Norway, in June 1990.
Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style: a statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council.
This first Utstein reporting guideline focused on out-of-hospital cardiac arrest (OHCA) and aimed to standardize definitions and data items, thus enabling comparison of cardiac arrest epidemiology and outcomes between emergency medical services systems. It was anticipated that this would also drive quality improvement, identify knowledge gaps, and facilitate clinical research by standardising reporting and definitions for use by investigators. The first Utstein reporting guideline for in-hospital cardiac arrest (IHCA) was published in 1997 and included 4 categories of variables for documenting in-hospital resuscitation: hospital, patient, arrest, and outcome.
Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital “Utstein style”: a statement for healthcare professionals from the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa.
Recommended guidelines for uniform reporting of pediatric advanced life support: the Pediatric Utstein Style: a statement for healthcare professionals from a task force of the American Academy of Pediatrics, the American Heart Association, and the European Resuscitation Council.
Utstein-style guidelines for uniform reporting of laboratory CPR research: a statement for healthcare professionals from a Task Force of the American Heart Association, the American College of Emergency Physicians, the American College of Cardiology, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Institute of Critical Care Medicine, the Safar Center for Resuscitation Research, and the Society for Academic Emergency Medicine.
In 2004, the Utstein guidelines for reporting cardiac arrest were updated to incorporate definitions and data elements for both OHCA and IHCA, reduce complexity of data collection, and address advances in resuscitation science.
Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa).
The Utstein reporting guidelines for cardiac arrest were revised again in 2015, but this update was confined to OHCA because of substantial differences between IHCA and OHCA epidemiology, process of care, and treatments.
Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resuscitation Registry templates for out-of-hospital cardiac arrest: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.
EuReCa ONE-27 Nations, ONE Europe ONE Registry: a prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe [published correction appears in Resuscitation. 2016;109:145–146].
Aus-ROC Steering Committee. Regional variation in the characteristics, incidence and outcomes of out-of-hospital cardiac arrest in Australia and New Zealand: results from the Aus-ROC Epistry.
Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation.
The American Heart Association Get With The Guidelines–Resuscitation (GWTG-R) registry has been a particularly valuable source of data on all aspects of IHCA,
and more recently, the UK National Cardiac Arrest Audit has also reported on the incidence and outcome from cardiac arrest in hospitals in the United Kingdom.
The experts involved in updating these Utstein IHCA reporting guidelines have drawn on the experience derived from GWTG-R and the UK National Cardiac Arrest Audit, and as with the recent revision of the OHCA reporting guideline, the proposals set out in this article aim to balance the desire for uniform collection of evidence-based factors associated with outcome and the practical challenges of real-life data collection and validation.
Methods
The Utstein collaborator group met face-to-face on four occasions to discuss the revisions to the Utstein IHCA reporting template. The first meeting followed the International Liaison Committee on Resuscitation (ILCOR) meeting in Melbourne, Australia, in April 2013. The second meeting occurred during a one-day ILCOR meeting in New Orleans, LA, in November 2016; the third meeting took place during a three-day ILCOR meeting in Adelaide, Australia, in May 2017; and the final face-to-face meeting took place during a three-day ILCOR meeting in Anaheim, CA, in November 2017. These face-to-face meetings were supplemented by five teleconferences that took place during 2016 to 2018.
The Utstein collaborator group agreed that whenever possible, there would be consistency with the definitions and data elements set out in the 2015 OHCA Utstein reporting guideline.
Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resuscitation Registry templates for out-of-hospital cardiac arrest: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.
Thus, core elements were defined as elements that all registries should aim to capture and report; these are considered the minimum recommended standard for quality assurance/improvement purposes. A core element is one that is considered both important and reasonably practical to collect and validate. Supplemental elements were defined as elements that were desirable but not essential to capture and report; such elements are more likely to be relevant to research than to quality assurance.
After the final face-to-face meeting in 2017, members of the IHCA Utstein Working Group considered core and supplemental data elements under the six domains of hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. A two-stage Delphi process was conducted using a web-based survey to achieve consensus for the recommendations for core and supplemental elements. During stage 1, the output from the IHCA Utstein Working Group was presented to the wider collaborator group comprising all members of the ILCOR Advanced Life Support, Basic Life Support, and Paediatric Task Forces. The ILCOR Neonatal Task Force was not included in this collaboration because this Utstein-style guideline does not include neonatal resuscitation, which is distinct from resuscitation of adults and children. Agreement for core and supplemental elements was sought using a five-point Likert scale, with 1 representing “do not agree” and 5 representing “strongly agree.” A score of 4 or 5 was deemed to be “agreement.” Participants were also able to submit additional elements for consideration. New elements, or elements for which there was <85% agreement on designation as core or supplemental, were submitted to a second round of voting. For the second round the collaborator group were asked whether the remaining variables should be supplemental or not included. There was >85% agreement for designations for all elements by the end of the second round, so further rounds were not required. Data definitions were based where possible on 2004 and 2015 Utstein definitions; some were adapted from the GWTG-R registry.
The IHCA Utstein Working Group, on behalf of collaborators, summarised the output from this process in a draft of the manuscript that was circulated and approved by the Utstein IHCA collaborators. The final manuscript was approved by the coauthors and ILCOR.
Results
IHCA Utstein Definitions
The Utstein elements were grouped into six domains (Figure). Each domain contained core and supplemental elements that are described in the Table.
Hospital Factors
Core hospital elements are the number of hospital admissions and the number of treated cardiac arrests per year. These data enable calculation of the incidence of cardiac arrest per 1000 admissions. There is variation in what constitutes a hospital admission; however, standardisation is essential because changing the denominator will have a major impact on cardiac arrest incidence. The consensus definition of hospital admission is admission to an in-patient bed; day cases are included, whereas outpatients or visitors are not. Cardiac arrests in the emergency department can be included in the registry, but the IHCA Utstein Working Group recommends that they be excluded for the purposes of calculating incidence of IHCA per 1000 admissions. The emergency department cardiac arrest patients who are included in the registry are those who have a cardiac arrest de novo in this location and not those who arrive in cardiac arrest or who rearrest after initial resuscitation from an OHCA. A cardiac arrest is defined as the delivery of chest compressions or defibrillation.
Strategies for improving survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations: a consensus statement from the American Heart Association.
In the paediatric population, this could include some patients who receive chest compressions for poor perfusion in the setting of severe bradycardia.
Supplemental hospital factors are the total number of deaths per year and a description of the number of hospital beds and facilities relevant to cardiac arrest (eg, 24/7 access to a cardiac catheterisation laboratory). An estimate of the number of deaths in patients with do-not-attempt cardiopulmonary resuscitation (DNACPR) decisions is provided by the difference between the total number of hospital deaths and the number of deaths after a cardiopulmonary resuscitation (CPR) attempt. We accept that there are limitations to this method for estimating the number of DNACPR decisions, not least because of double counting; for example, a patient may have a cardiac arrest with return of spontaneous circulation (ROSC) and then die with a subsequent DNACPR decision.
Patient Variables
Core patient variables are date of birth and sex. Among the supplemental patient variables, there was consensus for following national guidelines for defining categories of race, because there is inevitable international variation in nomenclature. Ideally, baseline neurological status would reflect the status before the index acute illness, but it was agreed that pre–cardiac arrest Cerebral Performance Category (CPC),
Recommended guidelines for uniform reporting of pediatric advanced life support: the Pediatric Utstein Style: a statement for healthcare professionals from a task force of the American Academy of Pediatrics, the American Heart Association, and the European Resuscitation Council.
was more likely to be collected at admission. Comorbidities influence outcome after IHCA, and the following have been evaluated previously for inclusion in the risk-standardisation model derived from the GWTG-R registry: heart failure, myocardial infarction, or diabetes mellitus; renal, hepatic, or respiratory insufficiency; baseline evidence of motor, cognitive, or functional deficits (central nervous system depression); acute stroke; acute nonstroke neurological disorder; pneumonia; hypotension; sepsis; major trauma; metabolic or electrolyte abnormality; and metastatic or haematologic malignancy.
There was agreement to include as supplemental data the preexisting conditions that were included in the final GWTG-R registry model: sepsis, hypotension, metastatic or haematologic malignancy, hepatic insufficiency, and renal insufficiency.
The following factors from the GWTG-R paediatric model were not included in the Delphi survey: pre-event characteristics (heart failure this admission, heart failure before admission, metabolic or electrolyte abnormality, acute nonstroke central nervous system event, baseline depression in central nervous system function, pneumonia, septicaemia, major trauma), and intravenous antiarrhythmic drug use in place at the time of cardiac arrest.
Pre-event core factors are the subject type (eg, outpatient, inpatient) and the illness category (eg, medical, surgical). It is well recognised that IHCAs are often not sudden, unexpected events; they are usually preceded by a period of deterioration evidenced by changes in vital signs.
It was agreed that the vital signs most proximate to the cardiac arrest would be valuable supplementary data but are difficult to collect and standardize; in the future, electronic data capture may make this easier.
Impact of introducing an electronic physiological surveillance system on hospital mortality [published correction appears in BMJ Qual Saf. 2015;24:717].
Of the possible interventions in place at the time of cardiac arrest, there was consensus to include as supplementary data continuous infusions of vasopressors or inotropes, invasive ventilation, noninvasive ventilation (including high-flow nasal cannula oxygen), extracorporeal membrane oxygenation, or ventricular assist device.
Cardiac arrest core process elements include the date and time of cardiac arrest, event location (the predefined locations and the number of options can be determined locally), whether the event was witnessed, and whether the resuscitation team was called. Documentation of whether monitoring was in place at the time of cardiac arrest is also core data; this would typically be electrocardiographic monitoring, but it could also include pulse oximetry. The first documented rhythm, application of an automated external defibrillator or manual defibrillator, and whether shocks or chest compressions were given are also core data. The final core item is use of extracorporeal cardiopulmonary resuscitation (ECPR). It was agreed that the IHCA Utstein definition of ECPR should align with that proposed by the Extracorporeal Life Support Organization
The Extracorporeal Life Support Organization Maastricht Treaty for Nomenclature in Extracorporeal Life Support: a position paper of the Extracorporeal Life Support Organization.
: “ECPR is the application of rapid-deployment venoarterial extracorporeal membrane oxygenation, usually by peripheral cannulation, to provide circulatory support in patients in whom conventional CPR is unsuccessful in achieving sustained ROSC. Sustained ROSC is deemed to have occurred when chest compressions are not required for 20 consecutive minutes and signs of circulation persist. ECPR implies the application of extracorporeal life support during conventional CPR. Use of extracorporeal life support initiated for low cardiac output after sustained ROSC is considered venoarterial extracorporeal membrane oxygenation.”
Nine supplemental cardiac arrest process elements are included. There was discussion on whether the airway intervention element should include the specific type of supraglottic airway used, but it was agreed that this would be left as a generic supraglottic airway. Ideally, the timing of these interventions (eg, drugs, airway) should be documented, because they are more likely to occur the longer the resuscitation attempt continues. The duration of resuscitation is strongly associated with worse outcome. In observational studies, this will bias the results toward a harmful effect of the intervention—an effect that has been termed resuscitation time bias.
The CPR quality element should include an indication of whether data are being used for real-time feedback or for quality assurance review. In keeping with Extracorporeal Life Support Organization nomenclature, ECPR start is defined as initiation of extracorporeal flow after cannulation and circuit connection to the patient.
The Extracorporeal Life Support Organization Maastricht Treaty for Nomenclature in Extracorporeal Life Support: a position paper of the Extracorporeal Life Support Organization.
Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association [published corrections appear in Circulation. 2013;128:e120 and Circulation. 2013;128:e408].
IHCA reports would optimally provide CPR hemodynamic data (eg, arterial diastolic blood pressure during CPR), potential proxies of CPR haemodynamics (eg, end-tidal carbon dioxide), or CPR mechanical data (eg, chest compression depth and rate, chest compression fraction).
Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association [published corrections appear in Circulation. 2013;128:e120 and Circulation. 2013;128:e408].
However, practical issues relegate the consideration of these important data to future updates of this template.
Postresuscitation Process
Targeted temperature management is defined as an active therapy to achieve and maintain a specific target temperature for a defined duration and is one of four core postresuscitation process elements. The other core elements are avoidance of pyrexia, coronary angiography (divided into urgent [within 2 hours after cardiac arrest] and delayed), and attempted coronary reperfusion (percutaneous coronary intervention or thrombolysis). There are 11 supplemental postresuscitation process elements. After considerable discussion, post–cardiac arrest pyrexia was defined as a temperature ≥38 °C within 72 hours after cardiac arrest. Documentation of vasopressor and inotrope infusions within the first 72 hours after ROSC is a supplemental element. Although the documentation of sedation and neuromuscular blocker use was also proposed, there was no consensus from the Delphi survey to include these items. The IHCA Utstein Working Group discussed this at length, because sedation is thought to be an important factor in delayed awakening after cardiac arrest.
Comparison of two sedation regimens during targeted temperature management after cardiac arrest [published correction appears in Resuscitation. 2018;131:135].
Although we have been faithful to the Delphi process and excluded sedation and neuromuscular blockers as supplemental items, the IHCA Utstein Working Group is supportive of local decisions to collect these data. Documentation of neuroprognostic tests should include both the types of tests and their timing.
Total hospital admissions. Admission is physical admission and recording of that admission to an in-patient bed. Day cases are included as admissions, but not outpatients or visitors.
Number of admissions/unknown
Number of treated in-hospital cardiac arrests per calendar year
Number of cardiac arrests. Cardiac arrest is defined by delivery of chest compressions and/or defibrillation.
Number of cases/unknown
Hospital – supplemental
Total number of hospital deaths per calendar year
Number of cases/unknown
Hospital description
To include total number of beds, number of ICU beds, number of pediatric beds, 24/7 cardiac catherization laboratory, use of rapid response system
Free text
Patient – core
Age
Date of birth
DD/MM/YYYY or MM/DD/YYYY or unknown
Sex
Sex
Male/female/unknown
Patient – supplemental
Race
Race
Follow national guidelines to define race categories
Out-of-hospital cardiac arrest
Did patient have an out-of-hospital arrest leading to this admission?
Yes/no/unknown
CPC/PCPC or mRS before cardiac arrest
CPC (or PCPC) or mRS score at baseline before acute illness or at admission to hospital
CPC 1–4, PCPC 1–5, or mRS 0–5/unknown
Preexisting conditions
Did the patient have preexisting conditions at time of event from following list: sepsis; hypotension; metastatic or hematological malignancy; hepatic insufficiency; renal insufficiency?
Yes/no/unknown
VAD
At the time of cardiac arrest, the patient is supported by any form of VAD to augment cardiac output and coronary perfusion.
Yes/no/unknown
Cardioverter-defibrillator
At the time of cardiac arrest, the patient has an internal or external cardioverter-defibrillator.
Internal/external/no/unknown
Pre-event data – core
Subject type
Patient category (eg, outpatient, inpatient)
Ambulatory/outpatient, emergency department, hospital inpatient, mental health facility inpatient, visitor or employee, unknown
Illness category
Medical, surgical, etc
Medical-cardiac, medical-noncardiac, surgical-cardiac, surgical-noncardiac, obstetric, trauma, other (visitor/employee), unknown
Pre-event data – supplemental
Date of hospital admission
Date and time of hospital admission
Documented date on which the individual who had the cardiac arrest was admitted to hospital/unknown
Vital signs most proximate to cardiac arrest
Enter vital signs most proximate to the cardiac arrest
Continuous infusion of vasopressors/inotropes or mechanical ventilation or noninvasive ventilation (including HFNC oxygen) or VV ECMO already in place when need for chest compressions and/or defibrillation was first recognised
Date/time the need for chest compressions (or defibrillation when initial rhythm was VF or pulseless VT) was first recognised/unknown
Event location
Event location (area)
Ambulatory/outpatient area; adult CCU; adult ICU; cardiac catheterization laboratory; delivery suite; diagnostic/intervention (other than catheterization laboratory); emergency department; general inpatient area; high-dependency unit; neonatal ICU; newborn nursery; operating room; pediatric ICU; pediatric cardiac intensive care; postanesthesia recovery room; rehabilitation, skilled nursing, or mental health unit/facility; same-day surgical area; telemetry unit or step-down unit; other (state); unknown
Event witnessed
A cardiac arrest that is seen or heard by another person or is monitored.
Yes/no/unknown
Resuscitation team called
Was a hospital-wide resuscitation response activated? Excludes a local response by the emergency department, operating room, or ICU teams, etc
Yes/no/unknown
Monitored cardiac arrest
Monitoring already in place when need for chest compressions and/or defibrillation was first recognised
ECG/other (specify)/unknown
Chest compressions
Did patient receive chest compressions (includes open cardiac massage)?
Yes/no/unknown
Initial rhythm
The first documented rhythm is the cardiac rhythm present at onset of cardiac arrest if monitored, or when the monitor or defibrillator is attached to the patient after onset of chest compressions.
Method(s) of confirmation used to ensure correct placement of tracheal tube or tracheostomy tube
Waveform capnography (waveform ETco2)/capnometry (numeric ETco2)/exhaled CO2 colorimetric monitor (ETco2 by colour change)/esophageal detection devices/ultrasound/revisualisation with direct laryngoscopy (tick all that apply)/none of the above/unknown
CPR quality
Mechanisms or processes in place during the resuscitation to measure the quality of CPR being delivered
Yes/no/unknown Indicate whether used for real-time feedback or for quality assurance review Waveform capnography/end-tidal CO2/arterial waveform/diastolic pressure/CPR mechanics device (eg, accelerometer, force transducer, TFI device)/CPR quality coach, metronome, other (specify) If CPR mechanics device (eg, accelerometer, force transducer, TFI device) used: average compression rate; average compression depth; compression fraction; chest compressions with complete release; average ventilation rate; longest preshock pause
If ECPR was used, when was it started?
If venoarterial extracorporeal membrane oxygenation was used, when was it started? ECPR start defined as initiation of extracorporeal flow to the patient after cannulation and circuit connection to cannulas
ECPR not used/time started/unknown
Postresuscitation process – core
TTM
TTM is defined as an active therapy to achieve and maintain a specific target temperature for a defined duration.
Yes/no/unknown
Avoidance of pyrexia
Defined as an active therapy to prevent pyrexia (temperature >38.0 °C)
Temperature at which active temperature management is started/unknown
Coronary angiography
Urgent coronary angiography defined as within 2 h of cardiac arrest; delayed coronary angiography defined as undertaken during the same hospital admission
Coronary reperfusion attempted using either PCI or thrombolysis
Type: PCI/thrombolysis/none/unknown Timing: Intra-arrest/within 24 h of ROSC/>24 h but before discharge/unknown
Postresuscitation process –supplemental
Patient transfer
Was the patient transferred to a specialist hospital (eg, providing 24/7 PCI, TTM, post-arrest hemodynamic support) for further treatment?
Yes/no/unknown
Time TTM initiated
If TTM was used, when was active temperature management started?
Not used/intra-arrest/post-ROSC/unknown
Target temperature
If TTM was used, what was the target temperature?
Not used/target temperature or range (°C)/unknown
Post–cardiac arrest pyrexia
Was there ever a documented temperature ≥38 °C within 72 h of cardiac arrest?
Yes/no/unknown Time pyrexia first documented
IABP
Was an IABP used?
Yes/no/unknown
LVAD
Was an LVAD used?
Yes/no/unknown
12-lead ECG interpretation
Interpretation of first 12-lead ECG after ROSC
STEMI/ischemic changes (not STEMI)/new LBBB/other
Oxygenation
After ROSC, was PaO2 or SpO2 targeted to a specific value?
Yes (state target range for Spo2 or Pao2)/no/unknown Duration
Neuroprognostic tests
Tests used to prognosticate outcome in comatose postarrest patients
Clinical examination: yes/no/unknown SSEP: yes/no/unknown EEG: yes/no/unknown NSE: yes/no/unknown CT brain: yes/no/unknown MRI brain: yes/no/unknown Other: Please specify Include timing for all tests
Vasopressors/inotropes
Did the patient receive any vasopressors/inotropes continuously by infusion in the 0- to 72-h period after ROSC?
Yes/no/unknown Specify vasopressor/inotrope
Targeted blood pressure management
What target blood pressure range was used?
Yes/no/target range/duration/unknown
Core outcomes
Date/time CPR stopped
Date/time sustained ROSC (lasting >20 min) began OR resuscitation efforts were terminated
Date/time/unknown
Reason CPR stopped
Survived event (sustained ROSC with spontaneous circulation, or return of circulation supported by ECPR) or died (efforts terminated, no sustained ROSC)
Survived (ROSC > 20 min)/died – efforts terminated (no sustained ROSC)/died – DNACPR in place before resuscitation attempt/unknown
Any ROSC
Was any documented return of adequate circulation in the absence of ongoing chest compressions (return of adequate pulse/heart rate by palpation, auscultation, Doppler, arterial blood pressure waveform, or documented blood pressure > 50 mm Hg systolic) achieved during the event?
Yes/no/unknown
30-d survival or survival to discharge
Was the patient alive at the point of hospital discharge/30 d?
Yes/no/unknown Record date of discharge if known
Neurological outcome at 30 d or hospital discharge
Record CPC/PCPC and/or mRS at 30 d or hospital discharge. Include a definition of how it was measured (face-to-face, extracted from notes, combination).
CPC score (1–5) or PCPC score (1–6)/unknown/not recorded; mRS (0–6)/unknown
Date and time of death if before hospital discharge
Recorded if patient dies before hospital discharge
Date and time/not applicable/unknown
Organ donation
Patients who had 1 or more solid organs donated for transplantation; DBD or DCD
Yes/DBD/DCD/no/unknown
Supplemental outcomes
Survival status at 12 mo
The patient is alive at 12 mo after cardiac arrest.
Yes/no/unknown
Withdrawal of life-sustaining treatment (including timing)
A decision to withdraw life-sustaining treatment was made; record the time that this occurred after ROSC.
Yes/no/unknown: days/hours
Cause of death
Cause of death
Sudden cardiac death/refractory hemodynamic shock/respiratory failure/neurological withdrawal of life-sustaining treatment/comorbid withdrawal of life-sustaining treatment
Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resuscitation Registry templates for out-of-hospital cardiac arrest: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.
There are seven core elements. It was agreed that the definition of “date and time CPR stopped” would be that used by the GWTG-R registry: “Date and time sustained ROSC (lasting >20 min) began or resuscitation efforts were terminated.” For the core item “reason CPR stopped,” there was considerable discussion on the use of the term futility, but it was eventually agreed not to include this. “Survived event” is defined as sustained ROSC or return of circulation supported by ECPR. The other option for “reason CPR stopped” is that the patient died (unable to achieve sustained ROSC). A DNACPR decision before the resuscitation attempt has also been added to the data options for this element. The working group noted that a previous American Heart Association consensus statement recommended that those resuscitation attempts that occur after a DNACPR decision has been made should not be counted in IHCA incidence or outcome measures.
Strategies for improving survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations: a consensus statement from the American Heart Association.
Knowledge of the number of patients with a DNACPR decision who inadvertently receive CPR when they have an IHCA is a useful quality measure for local systems of care.
Any ROSC is a core outcome element and is defined by return of circulation in the absence of ongoing chest compressions (return of adequate pulse/heart rate by palpation, auscultation, Doppler, arterial blood pressure waveform, or documented blood pressure >50 mm Hg systolic). There was considerable discussion about the evidence for using systolic blood pressure >50 mm Hg as one of the criteria for any ROSC. The IHCA Utstein Working Group agreed that it was preferable to make a statement on this topic rather than stay silent, because many patients with IHCA have invasive arterial blood pressure monitoring. Systolic blood pressure >50 mm Hg is recommended by others to discriminate hypotension from a pulseless electrical activity cardiac arrest, and there are limited data indicating that a pulse is often not palpable once the blood pressure is <60 mm Hg.
Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study.
Pulseless electric activity: definition, causes, mechanisms, management, and research priorities for the next decade: report from a National Heart, Lung, and Blood Institute workshop.
Ultimately, it was agreed that this was, at best, “expert opinion” and is a knowledge gap. Neurological outcome at 30 days or hospital discharge is recorded as either CPC/Paediatric CPC or mRS score and can be measured by face-to-face or telephone interview, extraction from the medical record, or a combination of the two. The CPC is a 5-point scale ranging from 1 (good cerebral performance) to 5 (dead), and the Pediatric CPC is a 6-point scale ranging from 1 (good cerebral performance) to 6 (dead). The mRS is a 7-point scale ranging from 0 (no symptoms) to 6 (dead). In keeping with the 2015 OHCA Utstein update, survival with favourable neurological outcome is defined as a CPC 1 or 2 or mRS 0 to 3 or no change in CPC or mRS from the patient’s baseline status.
Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resuscitation Registry templates for out-of-hospital cardiac arrest: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.
The Core Outcome Set for Cardiac Arrest Collaborators recommend the mRS over the CPC because the latter lacks discrimination between scores and has the potential for ceiling effects and overestimation of function.
The core outcome of organ donation includes documentation of either donation after brain death or donation after circulatory death. Date and time of death if before hospital discharge is the final core outcome; in some healthcare systems, date of death can be relatively easily tracked after hospital discharge. This should be included if possible.
There are four supplemental outcome elements. The cause of death can be obtained from the medical records and death certificates; however, death certificates are generally considered to be an unreliable source for cause of death.
Investigators have recently proposed five categories for cause of death after cardiac arrest: sudden cardiac death, refractory haemodynamic shock, respiratory failure, neurological withdrawal of life-sustaining treatment, and comorbid withdrawal of life-sustaining treatment.
The IHCA Utstein Working Group agreed that these should be included as data options. Health-related quality of life measurements are a supplemental outcome. The Core Outcome Set for Cardiac Arrest Collaborators suggested that health-related quality of life could be assessed at 180 days or 1 year or both; however, they recognised that the longer duration of follow-up is likely to be logistically more challenging.
The consensus among the IHCA Utstein collaborators was that health-related quality of life measurements are ideally measured at 12 months.
Implementation
Implementation of the IHCA Utstein reporting guideline will facilitate comparison between IHCA registries throughout the world. Use of standardised definitions will enable consistent recording and reporting of IHCA data and will allow reliable documentation of trends in interventions and outcomes. Reliable documentation of the incidence of cardiac arrest is an important performance indicator, because this can be reduced by (1) early detection of the deteriorating patient and instigation of treatments to prevent cardiac arrest
Thus, the incidence of cardiac arrest is a key performance indicator that can be used to track the effectiveness of rapid response systems in preventing cardiac arrest and the implementation of DNACPR decisions to ensure that CPR is attempted only when appropriate. There are challenges in using the incidence of cardiac arrest per 1000 hospital admissions to compare performance among hospitals, because this will be influenced significantly by external factors such as the proportion of elective admissions versus emergency admissions and the type of hospital, as well as by the variability in proportion of patients at each hospital with advanced directives. This can be mitigated to some extent by use of risk adjustment for hospital characteristics when hospitals are compared.
As for the OHCA Utstein reporting guideline, there are substantial challenges in striking a balance between including as core data those factors that are deemed essential for quality assurance purposes while including only those data that can be collected relatively easily and reliably in different healthcare systems globally. If too many items are deemed core, or if they require considerable resources to enable reliable collection, only a few hospitals will comply with the IHCA Utstein reporting guideline, which will limit participation in a national registry. If only a small proportion of hospitals participate in the registry, the generalizability of the findings is limited. This, in turn, reduces the value of international comparisons. Although supplemental items are not deemed essential, the IHCA Utstein Working Group recognizes the importance of research in guiding and validating quality assurance/improvement and encourages collection of supplemental items when practicable.
Conclusions
Utstein-style guidelines standardise reporting of the process of care and outcomes for patients with cardiac arrest. This update of the IHCA Utstein reporting guideline includes 6 domains: hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. This consensus IHCA reporting template adopts the style of the recently updated OHCA version.
Disclosures
Writing Group Disclosures
Tabled
1
Writing Group Member
Employment
Research Grant
Other Research Support
Speakers’ Bureau/ Honoraria
Expert Witness
Ownership Interest
Consultant/ Advisory Board
Other
Jerry P. Nolan
University of Warwick, Royal United Hospital (United Kingdom)
National Institute of Healthcare Research (PARAMEDIC-2 and AIRWAYS-2 study grants)*
None
None
None
None
None
None
Lars W. Andersen
Aarhus University (Denmark)
None
None
None
None
None
None
None
Robert A. Berg
Children’s Hospital of Philadelphia
None
None
None
None
None
None
None
Farhan Bhanji
McGill University (Canada)
None
None
None
None
None
None
None
Paul S. Chan
Mid America Heart Institute and the University of Missouri-Kansas City
NHLBI†
None
None
None
None
None
None
Michael W. Donnino
Beth Israel Deaconess Med Center
None
None
None
None
None
None
None
Swee Han Lim
Singapore General Hospital (Singapore)
None
None
None
None
None
None
None
Matthew Huei-Ming Ma
National Taiwan University Hospital (Taiwan)
None
None
None
None
None
None
None
Peter T. Morley
University of Melbourne (Australia)
None
None
None
None
None
None
None
Vinay M. Nadkarni
Children’s Hospital Philadelphia
None
None
None
None
None
None
None
Gavin D. Perkins
Warwick Medical School and University Hospitals Birmingham NHS Foundation Trust (United Kingdom)
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.
Reviewer Disclosures
Tabled
1
Reviewer
Employment
Research Grant
Other Research Support
Speakers’ Bureau/Honoraria
Expert Witness
Ownership Interest
Consultant/Advisory Board
Other
Lorrel E. Brown
University of Louisville
None
None
None
None
None
None
None
Daniel M. Christensen
Copenhagen University Hospital Herlev and Gentofte (Denmark)
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
Acknowledgements
The writing group acknowledges the American Heart Association Emergency Cardiovascular Care staff, in particular Eileen M. Censullo, MBA, FAARC, RRT, for her dedication and support in the preparation of this manuscript.
JPN ran the Delphi surveys and prepared the first draft of the manuscript under the oversight of RAB, JS, and GDP. The draft manuscript was revised after input from a core writing group initially (JPN, RAB, LWA, FB, PSC, MWD, SHL, MH-MM, VMN, MAS, GDP, PTM, and JS). These outputs were then circulated and discussed in detail with coauthors who added important intellectual content to the manuscript’s refinement. The final manuscript was approved by all authors and collaborators.
Appendix A.
Along with the writing group, the IHCA Utstein Collaborators include Richard Aickin, BMedSc, MbChB, DCH; Dianne L. Atkins, MD; Katherine M. Berg, MD; Robert Bingham, MB; Bernd W. Böttiger, MD, DEAA; Steven C. Brooks, MD, MHSc; Clifton W. Callaway, MD, PhD; Maaret Castrén, MD, PhD; Sung Phil Chung, MD, PhD; Julie Considine, RN, PhD; Thomaz Bittencourt Couto, MD, MS; Allan R. de Caen, MD, FRCP(C); Charles D. Deakin, MA, MD, FRCP, FRCA, FFICM, FERC; Ian R. Drennan, ACP, BScHK, PhD(c); Raffo Escalante, MD; Raúl J. Gazmuri, MD, PhD; Anne-Marie Guerguerian, MD, PhD; Mary Fran Hazinski, RN, MSN, FAHA; Peter J. Kudenchuk, MD; Bo Løfgren, MD, PhD, FAHA; Ian Maconochie, FRCPCH, FRCEM, FRCPI, PhD; Mary E. Mancini, RN, PhD, NE-BC, FAHA, ANE; Peter A. Meaney, MD, MPH; Robert W. Neumar, MD, PhD, FACEP, FAHA; Kee-Chong Ng, MbBS, MMed (Paeds); Tonia C. Nicholson, MD, FACEM; Chika Nishiyama, RN, PhD; Gabrielle A. Nuthall, MBChB, FRACP, FCICM; Theresa M. Olasveengen, MD, PhD; Edison F. Paiva, MD, PhD; Michael J. Parr, MB, BS, FRCP, FRCA, FANZCA, FJFICM; Amelia G. Reis, MD, PhD; Joshua C. Reynolds, MD, MS; Giuseppe Ristagno, MD, PhD; Claudio Sandroni, MD; Stephen M. Schexnayder, MD; Barnaby R. Scholefield, MRCPCH, PhD; Michael A. Smyth, MSc; David Stanton, CCA; Janice A. Tijssen, MD; Christian Vaillancourt, MD, MSc, FRCPC, CSPQ; Patrick Van de Voorde, MD, PhD; Tzong-Luen Wang, MD, PhD; and Michelle Welsford, BSc, MD, FACEP, CCPE, FRCPC.
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