Operator:It is now my pleasure to turn today’s program over to Liz Olson with the American Heart Association. The floor is yours

Liz Olson: Thank you so much. On behalf of the American Heart Association and Get With The Guidelines Resuscitation, I would like to welcome everyone to today’s webinar: Using Get With The Guidelines - Resuscitation Data to Impact Care. My name Liz Olson and I'm the National Program Manager for Get With The Guidelines Resuscitation.

On today's webinar we have the pleasure to hear from three presenters whose experience using Get With The Guidelines Resuscitation Data to Impact Care in their hospitals. We'll also look at opportunities for using Get With The Guidelines Resuscitation Data as a tool to impact resuscitation research. This session will offer an opportunity for Q&A with our speakers at the end of today’s session and we encourage your feedback and participation in this event. We'll have an opportunity for Q&A for all of our presenters at that time and you can submit questions throughout today's presentation by using the “Q&A” button in the lower corner of the screen. A recording of today’s webinar along with slides will be made available on the American Heart Association website, heart.org/quality.

It is my pleasure to now introduce our speakers for today. Our first presenters are from the University of Texas Medical Branch-Galveston, in Galveston, Texas. Odette Comeau has more than 30 years of experience in nursing. Ms. Comeau has worked primarily in adult critical care with medical and cardiac patients. Her current role is as an adult critical care clinical nurse specialist. She's the nursing chair of the Resuscitation Committee and also has administrative responsibility of the institution’s Medical-Surgical Rapid Response Program. Keith Ozenberger has more than 33 years of experience in healthcare, both in pre-hospital and hospital settings. His current role is as the Coordinator of the Education Lab at UTMB, which is the department that provides courses for healthcare professionals on emergency, cardiac care, including ACLS, BCLS, PALS, and others. Keith is a member of Resuscitation Committee and is responsible for all data extraction and entry in hospital codes into the Get With The Guidelines database. Following the presentation from UTMB today, we'll hear from Dr. Paul Chan. Dr. Chan is a professor of Internal Medicine at the University of Missouri, Kansas City and is chair of the Get With The Guidelines Resuscitation Clinical Working Group. He's internationally recognized as a leader in cardiac arrest and cardiovascular outcomes research. Trained at both Johns Hopkins and the Harvard School of Medicine, Dr. Chan has his master's degree in biostatistics and clinical trial designs. He's a cardiologist by training. Dr. Chan has conducted a number of his seminal studies examining the epidemiology, processes of care and outcomes of in-hospital cardiac arrests. These include three New England Journal of Medicine papers on time to defibrillation, long-term outcomes, and trends in survival after in-hospital cardiac arrest. He has HM papers in over 110 publications in total. Most recently has secured NIH funding to define best practices for in-hospital cardiac arrest.

I'll begin by turning our presentation over today to our presenters from UTMB Galveston. The floor is yours.

Keith Ozenberger:Thank you, my name is Keith Ozenberger and, again, it's our pleasure to make this presentation on Using Get With The Guidelines - Resuscitation to improve our hospital resuscitation. Just for reference, this is a map in the upper right-hand corner, the red star represents where Galveston is located. We are an island about 50 miles south of Houston. As you see from the picture, the UTMB campus is on the far east end of the island. In the foreground, you can see the Gulf of Mexico and the beach and in the background is Galveston Bay.

September 2008, Hurricane Ike made landfall here in Galveston, as you can see. A quite sizable storm, the storm surge caused a lot of havoc for everyone living in the area, including UTMB. September 13th, the morning after landfall, as you can see, every building on our campus was flooded with anywhere from 3 to 15 feet of water. A little marker that says Hurricane Ike high water, you can find in most buildings around, in fact, all of Galveston, showing where the flood lines waters rose. Here are just some pictures that next day throughout the island, not only on our campus but other areas of Galveston Island, showing the extent of some of the damage that was caused by Hurricane Ike.

Because of Hurricane Ike, we had to close for a while. We reopened as a 200-bed hospital in January of 2009, down from 550, which resulted, obviously, in some layoffs for a while. Our Emergency Department did not reopen until August of 2009. Because of some of these changes, participants in leadership in resuscitation committee changed and we started taking this time to review our data to recommit to a process of education and closer monitoring of our resuscitation.

Today we're not just that full, small hospital. The picture on the left is actually a new hospital building that we will be opening and moving patients into on Saturday, as well as expanding, on our right, several pictures of campuses away from Galveston as we are trying to continue to grow.

With our return in 2009, starting to review the data, we started noticing some changes that needed to occur. Of course, we have been a Get With The Guidelines participant since January of 2005. As you can see, the slide on the left, these are a couple of snapshots of what mostly concerned us in 2009. The first one on the left is what we were seeing in getting the time to first shock under two minutes when a patient was in defib. On the left is our percentage. All hospitals in the blue, and into the green all Texas hospitals. We noticed that we were doing quite poorly in that. We were down under 50%. On the right was first administration of IV-Epi. Again, we were fairly close with everyone but we weren't happy with the fact that it was under 80%. So this is what drew our attention to trying to reorient and work with our staff.

The Resuscitation Committee at UTMB meets once a month. As you see from list, it is a multidisciplinary committee that not only has members from the medical side but also from several of support services. Our strategy in trying to come up with improvements covered the following four areas: code review, mock codes, documentation revision, and various forms of feedback.

First of all, code review. Here is a template that we use for reviewing all our non-intensive care unit codes each month. It just gives us an idea of something to look at for quality, from anything from the start time to end time of the code, how quickly the Code Team got there, some of the things that were done during the resuscitation, as well as some things that were done prior, and identifying strengths and weaknesses.

Mock codes, probably one of the most helpful things. In some of our areas, my department, the Life Support Education Lab, heads that up. Picture here is two of my instructors that primarily do a lot of the mock codes along with one of our mannequins that we use. We focus, again, on the non-ICU staff prior to Code Team arrival, making sure they're quite comfortable with equipment, their skills and CPR, teamwork, and above all, it is used -- for that staff, it is a surprise. Only the nurse manager knows ahead of time if a mock code is going to be on the unit. Here is just another set of pictures from a mock code that we did in one of our non-intensive care unit areas. And this final shot was actually of one requested by an ICU nurse manager. This is actually in our Burn Intensive Care Unit being conducted, two of the pictures in the tub room, and then one picture of the critique following the mock code.

Odette Comeau:All right, good afternoon, everyone. My name is Odette Comeau, and I'll be doing the remainder of the presentation today and talking about the last two strategies.

So the next one is documentation revision. So, you know, we began reviewing these codes and we were looking and seeing what was happening and at what time and we would review, for example, a code of a patient in defib and we’d look at the code flow sheet and according to the documentation it appeared that, for example, we weren't doing CPR. And so we would go back to our code responders, especially our documenters, and say, wow, you know, it looks like you really didn't -- weren't doing CPR. Of course they looked at us and said, well, of course we were. So as we began doing that, what we began to realize is that really our documentation was not set up in such a way to allow us to be successful in really capturing some of those key activities that we really needed to be capturing. So that was one thing that we noted.

And then we started looking into our Electronic Medical Records because we also do have that. Our code flow sheets, I will mention, are still on paper at this time, but the position does do a note in the Electronic Medical Record. And so we began looking at code note templates, and for some reason, over the course of time, it seems that we accumulated nine of them, and we have no idea how that happened. Different services have different code note templates and they all had different content. So we, again, began to realize that we really needed to clean that up. So we got all the services

together in a room and said, all right, we need one template and we also decided it needed to be really streamlined and ultimately referred the reviewer to the code flowsheet, because that's really where all the detail is captured. Now, this documentation revision probably took about a year really to get it all done, but the one comment that I'll make, though, is this was an easy fix and it actually made a huge difference for us. I'll share that with you here in just a little bit.

So then the last strategy that we really ramped up is feedback, and that includes both formal and informal and then also in the classroom. So first of all, formal and informal. So we began referring things to different quality committees. An example of that would be Internal Medicine department because our medicine resident is who runs our adult codes. So when we have things that would fall outside of guidelines, you know, we were delayed in administering epi or whatever, we would refer that to those quality committees for them to review. We also really ramped up feedback to documenters, and that included opportunities and strengths as well, letting them know when they did a really good job. And then by virtue of reviewing the last known set of vital signs before the code, what we also would sort of stumble on inadvertently would be failure to rescue. So we would take screenshots of those vital signs and then follow up with the respective nurse managers so they could follow up on their end as well. We had multiple different things sort of going on. But also where our data really came in handy is that when Keith and his colleagues are teaching ACLS and BCLS, whenever we would have opportunities for improvement, they would reinforce that in the classroom setting. So that becomes a really excellent venue to really use your data for that as well.

All right, so how did we do? Did all these things make a difference? That's what I'll talk about next. So on this next slide, this is our data, and it's 2009 through 2016. And I've got a blue arrow there, that's 2013. And this is time to first compressions. And so in January of 2013 is when we fully implemented our revised code flowsheets and also rolled out the revised Electronic Medical Record code note. So you can see here that we jumped up immediately, really, and then we've been able to continue to sustain and improve even further. And so this is just an example of how something as simple as just making sure that whatever you're using to document your codes on is really helping you to be successful.

On this next slide, on the left-hand slide, Keith showed you earlier the time to epinephrine and vasopressin, and so we were at 80% and we thought, okay, we can certainly do better than that. So on the right-hand side, once again this is 2009 to 2015, and you can see how over the course of time we have also improved in this area and been able to sustain that improvement. And again, this is where the feedback comes into play, referring things to quality committees, giving people feedback, really, really important for this area.

And then finally, this is by far our most significant improvement, and it needed to improve. Again on the left, Keith talked about our time to first shock. So not only -- on the left you can see not only were we extremely dismal, actually, but we were also much

below our benchmarks. And so on the right-hand side, once again this is us from 2009 to 2015, this is by far our biggest improvement and we have, again, been able to sustain that. And this is where those mock codes are key. It's getting that first shock on board quickly. So this means your med-surg nurses really need to be comfortable and competent and not be afraid of the AEDs on your code carts. That is key. We now have several cases of saved from a med-surg nurse getting that first shock on board before the Code Team even arrives. And that's key, and that's key for really making sure that we have good patient outcomes.

So in 2014 we were very excited, after making all these improvements, to learn that we had achieved gold level performance by the American Heart Association and we were very, very excited by that. And we also learned this same year that we were the first in the state of Texas to achieve gold. And so we were very, very excited about that as well. So after that we thought, well, gosh, what is next after gold? And it turns out you can actually win gold sequential years. So last year in 2015 we were once again awarded with gold level performance for our resuscitation outcomes, having maintained that for another two consecutive years in a row. So we’re very excited. We don't know yet about 2016. We have been told unofficially that we sort of meet criteria but we have not heard any official feedback yet, so we're just sort of keeping our fingers crossed and hoping that we'll get some good news in about a month or so.

All right, so what do we look at with Get With The Guidelines? We look at the data sort of quarterly and annually, and what we look at really depends on what we're working on that time. As we work on different projects and we're trying to improve different things, we'll query different data. You can see here some examples on this slide of just different things that we have queried at different times, again, depending on what our quality projects are at that time, what we're looking at, things of that nature.

Some of the benefits for us of Get With The Guidelines are that first of all, it's very comprehensive. So those of you that do data entry know that there are just all kinds of data points entered in there, so you can query just a wide variety of things. We also really appreciate the opportunity for benchmarking, so seeing how we're doing in comparison to other facilities. Other ways that we've used the data are -- one example is that we -- we're getting ready to deploy new defibrillators on our code carts and when making decisions on which devices to purchase we would query the Get With The Guidelines database to try to find out things like, you know, what percentage of our codes do we end up having to defibrillate our patients, how many shocks is it requiring, what are the energy levels, and actually that data became very helpful for us to decide which defibrillators to purchase. Other examples are making code cart equipment revisions. So when we were getting ready to remove central lines or when we’re getting ready to change medications, we query the database to find out, well, how many times in the last year have we used that med or so on and so forth. So we've used it just in a variety of different ways and it's been a very, very useful tool for us.

All right, so what are our lessons learned? So I'll kind of lump the first two bullets together and say low-hanging fruit, always go for that, and things that are obvious and

even small changes count. So I think for us the good example for that would be the changes in the documentation. Again, something very simple, really, and yet allowed us to capture important data that needed to be captured but that our previous forms were just not allowing us to be successful in doing.

The next one, hard wiring, I just cannot overemphasize the importance of practice, practice, practice. Making sure that your med-surg nurses, in particular, are very, very comfortable with that AED, making sure everyone knows what is in your code cart and so on and so forth.

Consistency. So Keith talked about the template that we developed for the purpose of actually reviewing our codes. So that way every time we reviewed a code, we were looking at the same thing over and over, and that's important so that you don't miss something key as you're reviewing all of your codes.

And then, of course, always important to celebrate and acknowledge the wins. So we’ve certainly tried to do a good job of that as well, making sure that our Code Teams and all those who participate are given the kudos that they really deserve, so that's always very important as well.

And then finally, I'll leave the last slide up here just a minute. This is the contact information for myself and Keith. The only comment that I will make, though, is that my phone number has changed as I recently moved to a new building. And so my new phone number is 409-266-7966. I'll repeat that. It's 409-266-7966. And the email addresses for both myself and Keith are also listed here. So if there are any questions that anyone has after the webinar, you're certainly more than welcome to contact either one of us. And with that, I thank you for your time and attention.

Liz Olson:Thank you so much. That was great, thank you, Odette and Keith.

We have some great questions coming in. I just want to remind everybody that we'll be accepting questions throughout the presentation and we'll have a time at the end of today's webinar to pose questions to all of our presenters for today. So just a quick reminder, you can submit questions throughout today's presentation at the Q&A box in the lower corner of your screen.

At this time, I'm going to turn our final presenter for today, Dr. Paul Chan. Dr. Chan, the floor is yours.

Paul Chan:Hello, everyone. First of all, thank you so much for the opportunity to spend time with you all today, and it's been a privilege working with the Registry over the past decade. It was a great presentation by Odette and colleagues, Ethan.

I wanted to first of all start off by noting a couple of things. You know, it's really, really important when we think about how do we impact cardiac arrest outcomes, it's impossible to do if one doesn't measure those outcomes or those processes to begin with, and it is a tribute to the work of folks at UTMB, that they have been able to not only measure but also act upon what they saw were the issues with their initial measurements. So congratulations to all the work that you all have been doing.

I'm going to spend the next 15 minutes talking about the Registry and the research that has been generated and how that has impacted cardiac arrest care. And without all the work of all the folks on the call who have been submitting the data, we couldn't do this without you. And we applaud all your energies and your dedication to this disease process, which oftentimes is ignored compared to other conditions like AMI or heart failure or pneumonia, but it's just as important and lethal.

So Using Real-World Registry Data to Affect Real World Outcomes. I don't have any specific disclosures from industry. I do receive NIH support with two grants.

All of you are familiar with this out-of-hospital scene, and certainly in the in-hospital setting when patients have cardiac arrest. And time is of the essence, more so than in any other disease process. And oftentimes the difference of one or two minutes can be the difference between meaningful neurological recovery to even death. And about 15 years ago when the Registry was launched, really the understanding of in-hospital cardiac arrest was really a black box. We really didn't have any large scale studies to even know how often were patients surviving and what are the things that seemed to impact care. We knew it was different than the out-of-hospital setting because patients are sicker and they have oftentimes very different etiologies for why they have a cardiac arrest when it occurs inside the hospital. And with the launch of what was previously known as the National Registry for CPR, now known as Get With The Guidelines Resuscitation, in 2000, we now have data to close to a quarter of a million in-hospital cardiac arrest cases, 250,000. We also have data on over 300,000 rapid response team activations across a subset of the hospitals, and hospitals ranging from small community rural hospitals to large urban centers numbering over 600 to 700 sites over the past 15 years. And over that time we have generated a body of knowledge, a number of papers have been written, close to 70 papers have been written in the academic literature.

And what I want to discuss with you all today in the next 10 to 15 minutes is the following. Number one, to provide some examples of research that has been generated that have been integral to our understanding of what is key and vital for in-hospital cardiac arrest care and how can these insights ultimately be used to influence care at your hospital, at each of our hospitals. Because when all is said and done, research is research and it's only as useful as it can be if it can save lives. And I'm going to give you some specific examples of what this research has been in this Registry, looking at time to defibrillation, code duration, some hospital resuscitation practices, and in-hospital cardiac arrest survival.

So the first, time to defibrillation. Some of you may be familiar with a paper that was published about a decade ago, really the first paper to look at what is the impact on delays in defibrillator for patients with in-hospital cardiac arrest when the initial rhythm is a pulseless VT or a ventricular fibrillation arrest. You know, we all knew intuitively that if the longer it takes time to delay defibrillation, the less likely one is to survive. But the question is: how less likely would this be? This was published in the New England Journal of Medicine and what we found in essence, this top table describes patients with defibrillation within two minutes as opposed to those with defibrillation after two minutes. And there were close to 7,000 patients. Two-thirds of them had defibrillation within two minutes and one-third had them delayed greater than two minutes. And return of spontaneous circulation was substantially higher in those within two minutes, two-thirds of patients were acutely resuscitated as compared to only half of those with delays. And when we looked at survival to discharge, 39% of those with prompt defibrillation survived to discharge as compared to 22%. So a huge 17% absolute difference in raw survival. And after adjustments for patient differences, we found pretty much the same, that patients with delays in defibrillation with greater than two minutes had adjusted odds ratio of .55, which means they were 45% less likely to reach ROSC, and had an adjusted odds ratio of .48, or they were 52% less likely to survive to hospital discharge. And among those who survived discharge, delays in defibrillation was also associated with worse outcomes. They had an odds ratio of .74, so even if they survived, delays in defibrillation was associated with a 26% lower odds of surviving with a CPC score of 1 or 2. So clearly this has substantial impact on patients with VF/VT arrests and when we looked at this minute-by-minute you can see graphically in the table that every minute of delay was associated with worse outcomes. So that if you move from two to three, three to four, et cetera, you find that the chances of surviving to discharge gets progressively worse. And this graded dose response in an adverse fashion shows the pathophysiological rationale for that.

That was time to defibrillation and delays. It was really the first paper describing process within the Registry. And then a subsequent paper that was published looked at how long we resuscitate patients and does it matter, meaning some hospitals might resuscitate patients a little bit longer than others, and when they do, does it seem to make a difference, even if they know that the vast majority of patients may die? And this was a paper that was published about four or five years ago in the Lancet, and it looked at duration of resuscitation efforts and survival after in-hospital cardiac arrest within Get With The Guidelines Resuscitation. And this graph -- let me orient folks to this graph, this figure. On the X axis is how long patients were resuscitated before achieving return of spontaneous circulation. And on the Y axis is the proportion of patients who ultimately, the cumulative proportion achieving ROSC. And as you can see, and as you get from zero to ten minutes we have about 20% of patients who achieve ROSC. As you go to 20 minutes, about 35% of patients achieve ROSC. As you get to 30 minutes you see that it's about 42% that achieve ROSC. But even beyond 30 minutes there's an incremental increase, although very much smaller, to about 47-48%. And this graph, what it really basically describes is that there are patients who are saved or at least who have survived the initial resuscitation after the first 20 minutes and even some after the first 30 minutes, but that longer resuscitations in some patients may

make a difference in terms of achieving ROSC. Now, what the authors did then is did something very novel. They looked at patients who died during the code, didn't achieve ROSC. And then they looked at how long were they coded for, assuming that if every patient was given a fair chance and these were patients who were not DNR in the Registry, obviously, that you would think that most patients would be given sort of a good shake, a fair shake in terms of resuscitation. It turns out that there's a lot of variability. A good minority of patients were resuscitated less than 15 minutes and the code was called. Now maybe there was a soft code or some other parameter that was going on, but even beyond 15 minutes, you can see some patients were coded up to 16-20 minutes, which seems to be the peak of those who died. So the time interval, the five-minute time interval with the most patients that was coded for that duration was 16 to 20 minutes before they died as opposed to other patients who were coded way beyond 30 minutes. Some of them, the ones that go beyond 60 minutes were patients who probably achieved return of circulation but not spontaneous circulation for 20 minutes. So they may have re-coded and that's why these codes beyond 60 minutes lasted much longer. You can see there's a bell curve. Some patients are coded a lot shorter and others are coded a lot longer.

And then the authors, what they did was they then calculated for each hospital what their mean code time was for patients who died during the code as a surrogate measure of how aggressively they resuscitated all patients, including those who achieved ROSC. And quartile one was 25% of hospitals with the shortest code duration and quartile four was the 25% of hospitals who had the longest duration of coding their patients. And what they found was that the return of spontaneous circulation rate was 45% in the shortest coding hospitals, and 51% in the highest coding hospitals. And the shortest coding hospitals, the mean code duration was about 16 minutes as compared to 25 minutes in the fourth quartile. So 9 minutes longer on average. And they found that there was 12% increase -- adjusted increase risk of achieving ROSC in hospitals that coded patients longest compared to the hospitals that coded them the shortest. When they looked at survival to discharge in the right side of this table you find that adjusted rate was 14.5% in the first quartile, the hospital quartile with the shortest coding duration, as compared to 16%, and that was translated, again, to a 12% increase risk of surviving a discharge. This 1.7 percent absolute difference doesn't seem large but it's really substantial when you think about the fact that the survival rate is low to begin with for patients with in-hospital cardiac arrest. What the office concluded is that code duration is variable across hospitals and across patients and hospitals that seem to code the patients more aggressively, whether they die or live, seem to have better outcomes, better survival outcomes.

The third research piece that I am describing to you is actually coming out today, believe it or not, JAMA Cardiology. And this was a survey that was done among Get With The Guidelines Resuscitation hospitals in the fall of 2014. And we sent the survey to our active hospitals at the time and of these, about 150 adult hospitals responded. And we surveyed hospitals on 44 resuscitation practices and some of the questions on leadership and culture to try to see whether or not there are specific resuscitation practices seem to identify hospitals with better survival rates. So we're talking about

survival to discharge, that's risk adjusted for differences across hospitals. And what we looked at was for those hospitals with the highest survival rates for their patients with in-hospital cardiac arrest, do they do things a little bit differently than other hospitals, and if so, what are these things that are different? And we survey things that range the whole gamut from mock codes to dedicated intensity and post resuscitation care, 24/7 in ICUs, review of codes, debriefing after codes, et cetera. And what we found -- and I'm afraid that I don't have a lot of details because I didn't have the PDF from the paper, but the main study findings was the following. There were really three practices, at least in this initial survey, that were identified to be associated, to be linked with higher survival rates at the top performing hospitals. And these three were more frequent cardiac arrest case reviews. Hospitals that didn't review the cardiac arrest cases but less than once quarterly did not do as well as hospitals that reviewed them monthly and quarterly. Hospitals that routinely monitored for interruptions of chest compression were more likely to have high survival rates for their patients with in-hospital cardiac arrest. And hospitals that identified that they had inadequate resuscitation training, that was a moderate or severe barrier at their hospital, had significantly lower survival rates for their patients with in-hospital cardiac arrest. There were some other things that seemed to initially suggest an association but maybe because of sample size didn't bear out or maybe because it wasn't really associated, included monitoring time to defibrillation and that may be because VT/VF only comprises one-fifth of all cardiac arrests in the hospital setting. The frequency of the immediate code debriefing seemed to suggest that those response relationship but it may have been underpowered with a p value of .65. The presence of intensive care specialists in hospital ICUs at all times, again, there was a seeming trend but it was not statistically significant.

So anyway, these were initial findings to try to get a better grasp of among those hospitals that seem to be really good top performers, at least for the hospital survival outcome, that is risk adjusted, can we identify what those practices may be. We are going to, as a follow-up from this initial study, we'll be conducting site visits at a cluster of Get With The Guidelines hospitals in the upcoming two years to better dig in greater depth what those resuscitation practices, those best practices will be. And so more to come in the foreseeable future.

And finally, one of the things we've been working hard within the Registry to do is not only to have you be able to query your process times and your survival rates, but we all know that patients -- comparing patient outcomes, especially with survival, across different hospitals is a little difficult because some hospitals have sicker patients, and more acute patients, or for whatever reason their in-hospital cardiac arrest patients may be very different from others. So we've developed the methodology to risk-standardize or risk adjust the survival rates for your patients with in-hospital cardiac arrest. Previously, you know, and even now as you query in the online real-time tool, results are unadjusted so although you can compare how you do if there are 100 patients who have an arrest and 25 survive, 25% survival rate, you don't know if you compare to another hospital with a 25% survival rate, whether or not it's really the same. Or if you have sicker patients, you might be doing better because you have a sicker population to begin with, or if you have cardiac arrest rhythms, which are more prone to death, like

asystole or PEA, although having the same raw rate of 25% might suggest you're the same, you're not.

So, for instance, if I pose this hypothetical example, which hospital has better outcomes? Hospital A with 22% survival rate for 100 in-hospital cardiac arrests, 10 of them were VT/VF, 90 of them were asystole or PEA, and Hospital B with the same survival rate of 22% but 50 of them are VT/VF, and 50 asystole or PEA. If the outcomes of survival are not risk adjusted, one could perhaps infer the hospitals are equal in their survival outcomes for in-hospital cardiac arrest. But if you dig a little deeper in Hospital A, although has a 22% survival rate they have 10 VT/VF arrests of which four survived or 40% survival for VT/VF, and 90 asystole/PEA, of which 18 were alive or 20% survival rate for asystole/PEA to comprise their 22% survival rate. And compare that with Hospital B where they have 50 VT/VF, of which 15 survived or 30% survival, and 50 were asystole or PEA, of which seven survived, or 14% survival rate. You can see that Hospital A is much better than Hospital B in terms of VT/VF survival and asystole/PEA survival but it’s confounded by the fact that the distribution of the rhythms are different. So the overall aggregate survival rate may be the same but you can see that Hospital A is performing better, at least according to rhythms of their patients, for both types of rhythms. And the risk adjusted survival rate that we’ve developed, not only does this for rhythm, but location, age, co-morbidities and other interventions present at the time of cardiac arrest, so that it gives a full-bodied picture of risk adjustment, so you can compare hospitals as an apples-to-apples comparison.

And when we did this, we created a model and I won't bore you with the statistics behind it. And there were really nine key variables that held true in predicting and risk standardizing outcomes: the age to have patient, the initial cardiac arrest rhythm, the location where the arrest occurred, whether or not the patient was hypotensive, had sepsis, malignancy, hepatic insufficiency, was mechanically ventilated or was on a continuous IV vasopressor at the time of cardiac arrest. We considered all the other variables as well but these were the variables that held true in the model.

So we've been calculating these rates for all participants within Get With The Guidelines Resuscitation Registry for their data in 2013 and 2014. We're awaiting the 2015 data to do that. Some of you may or may not have been aware that this is actually available online within Get With The Guidelines Resuscitation on the webpage under "my reports" section, you can find that there is the Get With The Guidelines Resuscitation Risk Adjusted Survival to Discharge reports, which you can download and get the report for your hospital. And that report provides a number of things. It provides your hospital's -- I'm just giving a sample site -- this is one site for year 2012, the risk-standardized survival and what quintile they fell in, meaning hospitals in the top quintile are quintile five and hospitals in the middle is quintile three. And this is also depicted graphically. The red arrow shows where your hospital falls. The dark black middle line is the median of all hospitals for that year. And you can see for the outcome of risk adjusted survival, how your hospital is doing along the continuum of outcomes for all Get With The Guidelines Resuscitation hospitals. And again, the meaning of each quintile is that quintile 5 is basically suggesting that your percentile rank is 81 to 99 or your outcomes

are better than at least 80% of the hospitals. And this is for 2013 and '14, the distribution of risk-adjusted survival for all active hospitals during that year. And as you can see, there's a range of outcomes, even when it's risk-adjusted. The median was about 21% and some hospitals did better and others did a little lower than the median. And so there's room for improvement across all hospitals, but hospitals can get a better sense as to where they fall along that continuum within this report.

So what I wanted to do today was to give you some examples of pragmatic research. We have really leveraged the data that all of you have worked so hard to submit to us so that we can help provide informative information back to sites for real world practice. We have conducted research over the years to show that time to defibrillation does make a difference. Code duration and how comprehensively we resuscitate patients does make a difference. But there are some resuscitation practices that affect survival or at least hospital standing and survival. And there is now a metric that we will be discussing later this month, Get With The Guidelines leadership, in having a separate award for risk-adjusted survival beyond the gold, bronze and platinum awards that have been mentioned previously for the process measures. This is going to be a standalone award to recognize hospitals that have superior survival outcomes each year. And I think the goal of this is ultimately to show that although processes are very important and affect outcomes, we also want to recognize hospitals that excel in saving patients who are on the brink of death.

In summary, I really want to just highlight that we’ve only begun to crack the shell, the front layer of our understanding of in-hospital cardiac arrest. The Registry has provided great knowledge over the past decade, but we still have to find those hidden gems, those best practices that underlie why some hospitals really excel in either process or outcomes for their patients with in-hospital cardiac arrest, keeping in mind that the ultimate goal is the patient in front of us that we care for every day. And ultimately, the three things that I think are key and critical for each of us who work in hospitals is number one, we can't fix and we can't improve what we don't measure. So it's critical that we begin systematically looking and checking and benchmarking how we're doing in terms of process measures and in terms of outcomes. The second is we need leadership. Leadership, both in terms of a resuscitation champion or champions at hospitals to really take this disease condition on but also hospital leadership. We need to engage and really involve the leadership so that they can fund support and really provide the foundation for the resources that you will need to take this on. And the third, as mentioned by the previous speaker, that we need to celebrate and build teamwork, because this is not easy work, as all of you know, but at the same time it's very rewarding work, especially when we see that it has made a difference in people's lives. I know that there are a number of you who probably have questions, so I'll stop here and open up the floor for questions. Thank you so much for your time.

Liz Olson: Thank you so much, Dr. Chan, that was a really good presentation, I appreciate that. At this time, I'm going to turn the moderation of our Q&A over to our national consultant for Get With The Guidelines Resuscitation, Tanya Lane Truitt, RN.

Tanya Truitt:Thank you, Liz. Before we begin to read our questions, Ethan can you remind everyone how to submit questions?

Operator:Sure, at this time we would like to take any questions you might have for us today. To ask a question via the web, click the “Q&A” button on the lower left-hand corner of your screen, type your question in the open area, and click the “submit” button.

Tanya Truitt:Great. thank you. Okay, so I think our first set of questions are for Keith and Odette. So I'll kind of run our way through those. The first one is: What type of EHR do you use?

Odette Comeau:Sure, this is Odette. So our EHR is EPIC.

Tanya Truitt:So I'm going to ask you a couple questions in conjunction with that. Can you speak to transferring documentation to your EMR? Did you have barriers, successes?

Odette Comeau:Probably our biggest barrier, it’s probably not unique to our facility, is just that there are always multiple projects from multiple people. We're all sort of competing for that, to try to get things implemented in our Electronic Medical Records. So when you submit a new project request that gets placed in a queue and then when your turn comes up, so to speak, then it does get built and then added to the Electronic Medical Record. And so that's probably our biggest barrier, is just the volume of new projects. But overall, actually, our EPIC department works very well with us and once our project does come up in the queue, the changes are relatively rapid and the new builds are very rapid and it's been very, very successful.

Tanya Truitt:Great. You have dedicated staff who enters data into Get With The Guidelines Resuscitation database?

Odette Comeau:We sure do. And that is Keith Ozenberger, sitting in my office right now with this webinar. Keith does 100% of the data extraction from our Electronic Medical Record and our code flowsheets and enters that into the database. And that is, of course, a huge monumental undertaking but I think the nice thing, too, is we have sort of that consistency in that the same person understands the database extremely well and is the person entering the data.

Tanya Truitt:

Great. Did you get pushback from staff with the mock codes when they were -- especially when they were really busy? Are the managers supportive in insuring that they get done when they are scheduled?

Keith Ozenberger:This is Keith. Yes, we sometimes we do get pushback. The main thing we try to do is get a manager to tell us if they have an open room in their unit or we try to make it like a patient arrest, but they usually work with us. We have even done things in conference rooms and just said, one of your staff members just passed out.

Odette Comeau:This is Odette. We've actually really tried to make that clear that, you know, we'll be flexible. If your unit is busy, then we'll do a code in the conference room or in the nurse manager's office. It really doesn't matter. The idea is to get people practicing. And at this point in the game, honestly, I think our staff are so used to David and Annette rolling up onto their unit that they're sort of used to it by now. And while I'm sure some, probably, you know, are not that thrilled initially, I will share with you that the number one question when it's all said and done that David and Annette get actually is: So when are you guys coming back? So in truth, in the end, the staff really appreciate the opportunity to get to practice those things so they don't feel like a fish out of water, so to speak, when the true event happens.

Tanya Truitt:Great. One of the questions is: Our hospitals struggle with post-code huddle. Any suggestions?

Odette Comeau:Yeah, that's a great question because we struggle with that as well. We’ve developed the tools to do that and we're getting ready to implement it. Our biggest challenge is that, you know we have code responders coming from all over the place and when a code is done, then everyone is -- strictly the patient is transferred to the ICU and the majority of code responders will end up dispersing, and so how do you sort of recollect people to do that post-code huddle? So that's a struggle for us as well and if anyone out there has any great suggestions on how to address that, we're certainly interested to find out ourselves.

Tanya Truitt:Great, thanks. The next question, I think, is for Dr. Chan. Dr. Chan, what are the current Get With The Guidelines Resuscitation in-hospital survival rates for hospital arrests? Can you present or give numbers for the CPA inside versus outside of ICUs, survival to discharging and things like that?

Paul Chan: You know, the survival rate has actually improved over the past 15 years. One was first began in 2002 period. The survival rate for the risk adjusted survival rate was about 13-15% during those first three years. And, again, this is adjusted for rhythm, location and

co-morbidities. In 2012 it was at 22%, and over the last two years, 2013 and 2014, it’s hovered close to 24%. So there's been not a total doubling, but a near doubling of the survival rate over time. The other question as to, you know, whether or not this is separated by ICU or not, the risk adjusted survival rate does adjust, so it analyzes essentially, you know, patients who arrest in the ICU differently and sort of compares them with other ICU arrests, so that it's taken into account. We don't provide a separate risk adjusted survival rate inside and outside the ICU, because the methodology would be different and there would have to be new models developed for it, and there wasn't a good rationale to do that. Each site can create and query the unadjusted raw survival rates outside and inside the ICU but, again, that doesn't compare apples-to-apples. So currently there's no report of risk adjusted survival inside and outside the ICU, but it has improved markedly over the past decade and a half.

Tanya Truitt:Great, thank you. Next question I believe is for Keith and Odette. Do you use a code narrator in EPIC or do you use your own documentation form?

Odette Comeau:So our code flowsheet where all the detail is documented is still on paper. That has not come up into the queue yet to be built into EPIC. What gets charged into EPIC is a summary of the code and that is in the form of a code progress note that the physicians document on.

Tanya Truitt:Excellent. We have time for one more question, and I believe that question will probably be for Odette and Keith again. Do you have a mock code checklist debriefing form tool that you're willing to share in your code sheet? There's many questions about sharing your code sheet as well. Can people just contact you to get copies of those?

Keith Ozenberger:Contact one of us and --

Odette Comeau:You can just email us.

Keith Ozenberger:Email us, we'll be glad to --

Odette Comeau:We'll share whatever we have.

Tanya Truitt:Excellent. Liz, I'll turn it back over to you.

Liz Olson:

Thanks so much. We have a lot of really great questions and we weren't able to get to all of them today, but we'll collect those and share those with our presenters so that we can share those along with the slides and the recording from today's webinar. So, again, just a huge thank you to our presenters today. It was really great content and I just appreciate your time and leading today’s webinar. Just a reminder, following today's event we'll have a recording of the webinar and presentation slides in a few weeks available on the American Heart Association website, heart.org/quality. And we'll send a notification out to everyone who attended today so you’ll know to take a look for that. We'll also be sending you an email for just a quick feedback survey to gather your input on today's webinar. I want to thank everyone for your time and attention and have a wonderful day.

Operator:Thanks to all our participants for joining us today. We hope you found this webcast presentation informative. This concludes our webcast. You may now disconnect. Have a great day.