Abstract 311: Trajectory of Risk-Standardized Survival Rates for In-Hospital Cardiac Arrest

Introduction: Risk-standardized survival rate (RSSR) for in-hospital cardiac arrest (IHCA) has emerged as an important metric to measure and incentivize resuscitation quality at a hospital-level. We examined whether hospital performance on the RSSR metric was generally stable year-over-year. Methods: We used data from 81,795 adult patients with an IHCA from 163 hospitals with continuous participation in Get With The Guidelines-Resuscitation from 2012 to 2017. A two-level hierarchical regression model was used to compute RSSRs for 2 time intervals (baseline: 2012-13; follow-up: 2014-17). Hospitals were classified as top-, middle- and bottom-performing if they ranked in the top 25%, middle 50%, and bottom 25% on the RSSR metric during 2012-2013. We examined the trajectory of top, middle, and bottom-performing hospitals’ RSSR during 2014-2017 (follow-up). Results: During 2012-2013, 41 hospitals were identified as top-performing (median RSSR 31.9%), 81 as middle-performing (median RSSR 24.9%) and 41 as bottom-performing (median RSSR 18.5%). During 2014-2017, more than 3/4 th (75.6%) of top-performing hospitals remained in the top 50% and 53.7% remained in the top 25% (Table). In contrast, most (81.5%) bottom-performing hospitals ranked in the bottom 50%, and 56.1% remained in the bottom 25% during 2014-2017. Performance of middle-performing hospitals on the RSSR metric was variable. Importantly, rankings improved by at least 1 quartile ( > 25 percentile points) at 26.8% and by at least 2 quartiles ( > 50 percentile points) at 12.2% bottom-performing hospitals (Table). Likewise, rankings at 31.7% and 19.5% of top-performing hospitals worsened by at least 25 and 50 percentile points during 2014-2017, respectively. Conclusion: Hospital performance on RSSR during a baseline period was generally consistent with their performance during follow up. However, percentile rankings changed markedly over time at a small proportion of top- and bottom-performing hospitals.

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Trajectory of Risk-Standardized Survival Rates for In-Hospital Cardiac Arrest

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.120.006514 ◽

2020 ◽

Vol 13 (9) ◽

Author(s):

Abdul H. Qazi ◽

Paul S. Chan ◽

Yunshu Zhou ◽

Mary Vaughan-Sarrazin ◽

Saket Girotra ◽

...

Keyword(s):

Cardiac Arrest ◽

Survival Rates ◽

Baseline Period ◽

Hospital Performance ◽

Hierarchical Regression ◽

Similar Proportion ◽

Large Improvement ◽

Hospital Cardiac Arrest ◽

Over Time

Background: A hospital’s risk-standardized survival rate (RSSR) for in-hospital cardiac arrest has emerged as an important metric to benchmark and incentivize hospital resuscitation quality. We examined whether hospital performance on the RSSR metric was stable or dynamic year-over-year and whether low-performing hospitals were able to improve survival outcomes over time. Methods and Results: We used data from 84 089 adult patients with an in-hospital cardiac arrest from 166 hospitals with continuous participation in Get With The Guidelines–Resuscitation from 2012 to 2017. A 2-level hierarchical regression model was used to compute RSSRs during a baseline (2012–2013) and two follow-up periods (2014–2015 and 2016–2017). At baseline, hospitals were classified as top-, middle-, and bottom-performing if they ranked in the top 25%, middle 50%, and bottom 25%, respectively, on their RSSR metric during 2012 to 2013. We compared hospital performance on RSSR during follow-up between top, middle, and bottom-performing hospitals’ at baseline. During 2012 to 2013, 42 hospitals were identified as top-performing (median RSSR, 31.7%), 82 as middle-performing (median RSSR, 24.6%), and 42 as bottom-performing (median RSSR, 18.7%). During both follow-up periods, >70% of top-performing hospitals ranked in the top 50%, a substantial proportion remained in the top 25% of RSSR during 2014 to 2015 (54.6%) and 2016 to 2017 (40.4%) follow-up periods. Likewise, nearly 75% of bottom-performing hospitals remained in the bottom 50% during both follow-up periods, with 50.0% in the bottom 25% of RSSR during 2014 to 2015 and 40.5% in the bottom 25% during 2016 to 2017. While percentile rankings were generally consistent over time at ≈45% of study hospitals, ≈1 in 5 (21.4%) bottom-performing hospitals showed large improvement in percentile rankings over time and a similar proportion (23.7%) of top-performing hospitals showed large decline in percentile rankings compared with baseline. Conclusions: Hospital performance on RSSR during baseline period was generally consistent over 4 years of follow-up. However, 1 in 5 bottom-performing hospitals had large improvement in survival over time. Identifying care and quality improvement innovations at these sites may provide opportunities to improve in-hospital cardiac arrest care at other hospitals.

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Abstract 252: The Association of Award Recognition From Get With the Guidelines-Resuscitation with Improved Survival Rates in In-Hospital Cardiac Arrest Events

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.9.suppl_2.252 ◽

2016 ◽

Vol 9 (suppl_2) ◽

Author(s):

Kathie Thomas ◽

Art Miller ◽

Greg Poe

Keyword(s):

Cardiac Arrest ◽

Quality Improvement ◽

Survival Rate ◽

Discharge Rate ◽

Survival Rates ◽

Improvement Program ◽

Award Winning ◽

National Survival ◽

Get With The Guidelines ◽

Hospital Cardiac Arrest

Background and Objectives: It is estimated that over 200,000 adults experience in-hospital cardiac arrest each year. Overall survival to discharge has remained relatively unchanged for decades and survival rates remain at about 20% (Elenbach et al., 2009). Get With The Guidelines-Resuscitation (GWTG-R) is an in-hospital quality improvement program designed to improve adherence to evidence-based care of patients who experience an in-hospital resuscitation event. GWTG-R focuses on four achievement measures. The measures for adult patients include time to first chest compression of less than or equal to one minute, device confirmation of correct endotracheal tube placement, patients with pulseless VF/VT as the initial documented rhythm with a time to first shock of less than or equal to two minutes, and events in which patients were monitored or witnessed at the time of cardiac arrest. The objective of this abstract is to examine the association between hospital adherence to GWTG-R and in-hospital cardiac arrest survival rates. Methods: A retrospective review of adult in-hospital cardiopulmonary arrest (CPA) patients (n=1849) from 21 Michigan, Illinois, and Indiana hospitals using the GWTG-R database was conducted from January 2014 through December 2014. This study included adult CPA patients that did and did not survive to discharge. Results: The review found that hospitals that had attained 84.6% or higher thresholds in all four achievement measures for at least one year, which is award recognition status, had a significantly improved in-hospital CPA survival to discharge rate of 29.6%. Hospitals that did not obtain award status had a CPA survival to discharge rate of 24.3%. The national survival rate for in-hospital adult CPA survival to discharge is 20%. Hospitals that did not achieve award recognition status still demonstrated improvement in survival rate when compared to the national survival rate, indicating the importance of a quality improvement program such as GWTG-R. No significant difference was found between in-hospital adult CPA survival rate and race between GWTG-R award winning and non-award winning hospitals. Hospitals that earned award recognition from GWTG-R had a survival to discharge rate of 30.2% for African Americans and 29.6% for whites. Hospitals that were did not earn award recognition from GWTG-R had a survival to discharge rate of 20.0% for African Americans and 20.1% for whites. Conclusions: Survival of in-hospital adult CPA patients improved significantly when GWTG-R measures are adhered to. Survival of in-hospital adult CPA patients also improves with implementation of GWTG-R. It is crucial that hospitals collect and analyze data regarding resuscitation processes and outcomes. Quality improvement measures can then be implemented in order to assist with improving in-hospital CPA survival rates.

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Abstract 114: Does Size Matter? Comparing Cardiac Arrest Survival to Discharge Rates Based on Number of Hospital Beds

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.11.suppl_1.114 ◽

2018 ◽

Vol 11 (suppl_1) ◽

Author(s):

Kathie Thomas ◽

Renaud Gueret ◽

Art Miller ◽

Gary Myers

Keyword(s):

Cardiac Arrest ◽

Survival Rates ◽

The United States ◽

Spontaneous Circulation ◽

Stressful Event ◽

Successful Resuscitation ◽

Discharge Rates ◽

Get With The Guidelines ◽

Size Matter ◽

Hospital Cardiac Arrest

Background and Objectives: In-hospital cardiac arrest can be challenging. The frequency of events outside of critical care units is typically low which makes it a stressful event for staff. According to the HEROIC study, there were 209,000 in-hospital cardiac arrests in the United States in 2016. Only 24.9% survived. Get With the Guidelines-Resuscitation is a quality improvement tool for hospitals to measure and evaluate their in-house codes and resuscitation rates. It may be assumed that survival rates are better at larger hospitals. The objective of this study was to examine the association between in-hospital cardiac arrest rates based on the bed size of a hospital. Methods: By using number of beds as a comparison and data from Get With the Guidelines-Resuscitation we sampled 46 hospitals in the eleven-state AHA Midwest Affiliate, (IL, IN, IA, KS, MI, MN, MO, NE, ND, SD, WI), comparing survival to discharge from cardiac arrest, with and without shockable rhythms from January 1, 2013-December 31, 2016. All patients are included in a risk adjusted formula that resides within Get With the Guidelines-Resuscitation. Results: In our comparison, we included hospitals with licensed and/or staffed beds of <100, 100-199, 200-299, 300-399 and 400 or more beds. Our data showed that higher sustained return of spontaneous circulation rates with survival to discharge are not dictated by the size of a hospital. In fact, in all 4 years shown, successful resuscitation rates were higher at hospitals with fewer beds verses larger facilities. Conclusions: Survival to discharge from in-hospital cardiac arrest is not dependent on hospital bed size. It is important that hospitals collect and analyze data regarding in-hospital cardiac arrests to improve survival rates beyond the 24.9% identified in the HEROIC study. A further examination looking at discharge destinations with CPC scores should be considered for a future study.

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Association Between Hospital Resuscitation Champion and Survival for In‐Hospital Cardiac Arrest

Journal of the American Heart Association ◽

10.1161/jaha.120.017509 ◽

2021 ◽

Author(s):

Jesse L. Chan ◽

Jessica Lehrich ◽

Brahmajee K. Nallamothu ◽

Yuanyuan Tang ◽

Mary Kennedy ◽

...

Keyword(s):

Cardiac Arrest ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Survival Rates ◽

Critical Factor ◽

Survival Outcomes ◽

Study Cohort ◽

Calculated Risk ◽

Get With The Guidelines ◽

Hospital Cardiac Arrest

Background Although many hospitals have resuscitation champions, it is unknown if hospitals with very active physician or nonphysician champions have higher survival rates for in‐hospital cardiac arrest (IHCA). Methods and Results We surveyed adult hospitals in Get With The Guidelines‐Resuscitation about resuscitation practices, including about their resuscitation champion. Hospitals were categorized as having a very active physician champion, a very active nonphysician champion, or other (no champion or not very active champion). For each hospital, we calculated risk‐standardized survival rates for IHCA during the period of 2016 to 2018 and categorized them into quintiles of risk‐standardized survival rates. The association between a hospital's resuscitation champion type and their quintile of survival was evaluated using multivariable hierarchical proportional odds logistic regression. Overall, 192 hospitals (total of 44 477 IHCAs) comprised the study cohort. Risk‐standardized survival rates for IHCA varied widely between hospitals (median: 24.7%; range: 9.2%–37.5%). Very active physician champions were present in 29 (15.1%) hospitals, 64 (33.3%) had very active nonphysician champions, and 99 (51.6%) did not have a very active champion. Compared with sites without a very active resuscitation champion, hospitals with a very active physician champion were 4 times more likely to be in a higher survival quintile, even after adjusting for resuscitation practices across hospital groups (adjusted odds ratio [OR], 3.90; 95% CI, 1.39–10.95). In contrast, there was no difference in survival between sites without very active champions and those with very active non‐physician champions (adjusted OR, 1.28; 95% CI, 0.62–2.65). Conclusions The background and engagement level of a resuscitation champion is a critical factor in a hospital's survival outcomes for IHCA.

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Abstract 350: Hospital Variation in Survival for Pediatric In-Hospital Cardiac Arrest: A Report From Get With the Guidelines -Resuscitation

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.6.suppl_1.a350 ◽

2013 ◽

Vol 6 (suppl_1) ◽

Author(s):

Natalie Jayaram ◽

John A Spertus ◽

Fengming Tang ◽

Paul S Chan

Keyword(s):

Cardiac Arrest ◽

Survival Rates ◽

National Registry ◽

High Performing ◽

Hierarchical Logistic Regression ◽

Hospital Survival ◽

Hospital Variation ◽

C Statistic ◽

Get With The Guidelines ◽

Hospital Cardiac Arrest

Background: Although survival after in-hospital cardiac arrest is likely to vary among hospitals caring for children, validated methods to risk-standardize pediatric survival rates across sites do not currently exist. Methods: Within the American Heart Association’s Get With the Guidelines-Resuscitation registry for in-hospital cardiac arrest, we identified 1,640 cardiac arrests in children from 168 hospitals from 2006 to 2010. Using multivariable hierarchical logistic regression, we developed and validated a model to predict survival to hospital discharge. We then applied the coefficients and random hospital intercepts from the model to examine risk-standardized rates of cardiac arrest survival for those hospitals with a minimum of 10 pediatric cardiac arrest cases. Results: A total of 15 patient-level predictors were identified: age, sex, race, cardiac arrest rhythm, location and day of arrest, mechanical ventilation, baseline depression in neurological function, major trauma, hypotension, metabolic or electrolyte abnormalities, renal insufficiency, sepsis, and use of intravenous antiarrhythmics or vasopressors at the time of arrest. The model had good discrimination (C-statistic of 0.71), confirmed by bootstrap validation (validation C-statistic of 0.69). Among 31 hospitals with at least 10 cardiac arrests, unadjusted hospital survival rates varied considerably (median, 37%; inter-quartile range [IQR]: 21% to 44%; range: 0% to 59%). After risk-standardization, variation in hospital survival rates persisted (median, 37%; IQR: 33% to 41%; range: 31% to 49%), although the range of outcomes narrowed considerably. Conclusion: In a large national registry, we developed and validated a model to predict survival after in-hospital cardiac arrest in children. Even with risk-standardization, there is significant variation in survival rates across hospitals. Leveraging these models, best practices can be assessed at high-performing hospitals and shared with others to improve care in the setting of pediatric cardiac arrest.

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Abstract 18274: Comparative Effectiveness of Stacked versus Single Shock Therapy for In-Hospital Cardiac Arrest: Insights from the Get With the Guidelines-Resuscitation Registry

Circulation ◽

10.1161/circ.130.suppl_2.18274 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Steven M Bradley ◽

Wenhui Liu ◽

Gary K Grunwald ◽

Paul S Chan ◽

Brahmajee K Nallamothu ◽

...

Keyword(s):

Cardiac Arrest ◽

Temporal Trends ◽

Shock Therapy ◽

Hierarchical Regression ◽

Time Interval ◽

Single Shock ◽

Post Shock ◽

Initial Shock ◽

Get With The Guidelines ◽

Hospital Cardiac Arrest

Background: Among patients with cardiac arrest due to ventricular tachycardia or ventricular fibrillation (VT/VF), guidelines emphasize single shock protocols to minimize interruptions in chest compressions that may impair patient outcomes. The adoption and impact of single shock protocols on survival of in-hospital VT/VF arrest is unknown. Methods: In the Get With The Guidelines - Resuscitation multicenter observational registry, we identified 4,114 adults with in-hospital cardiac arrest due to VT/VF between 2004 and 2012, an immediate post-shock rhythm of VT/VF following the initial defibrillation attempt, and a second defibrillation attempt within 3 minutes of the first shock. The time interval in minutes from the initial shock to second shock was used to define stacked shock (time interval of 0 to 1 minute) and single shock protocols (time interval of 2 to 3 minutes). We first evaluated temporal trends in the use of stacked versus single shock protocols. We then used hierarchical regression adjusting for patient arrest characteristics and comorbidities while accounting for clustered observations by hospital to determine the association between stacked versus single shocks for VT/VF and survival to discharge. For this analysis, we restricted our cohort to the 2,984 (72.5%) patients with VT/VFarrest occurring at one of 150 hospitals with the use of both stacked and single shock approaches and at least 10 events during the study period. Results: The proportion of patients receiving a single shock protocol for VT/VF following an initial defibrillation attempt doubled from 25% in 2004 to more than 50% in 2012. Compared with patients treated with stacked shocks, treatment with single shocks was associated with a lower risk-adjusted survival to discharge (odds ratio 0.81, 95% confidence interval 0.68 to 0.98, P=0.03). Conclusion: Among adults with in-hospital VT/VFarrest, use of single shocks has increased since 2004 in accordance with guideline recommendations. However, compared with stacked shocks, single shocks for VT/VF was associated with decreased odds of survival to discharge. These observational findings suggest further investigation is needed to define the optimal defibrillation strategy for management of in-hospital VT/VF arrest.

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Patterns of Resuscitation Care and Survival After In-Hospital Cardiac Arrest in Patients With Advanced Cancer

Journal of Oncology Practice ◽

10.1200/jop.2016.020404 ◽

2017 ◽

Vol 13 (10) ◽

pp. e821-e830 ◽

Cited By ~ 12

Author(s):

Jeffrey T. Bruckel ◽

Sandra L. Wong ◽

Paul S. Chan ◽

Steven M. Bradley ◽

Brahmajee K. Nallamothu

Keyword(s):

Cardiac Arrest ◽

Advanced Cancer ◽

Hematologic Malignancy ◽

Survival Rates ◽

Quality Measures ◽

Spontaneous Circulation ◽

Adjusted Relative Risk ◽

Advanced Cancer Patients ◽

Get With The Guidelines ◽

Hospital Cardiac Arrest

Purpose: Little is known regarding patterns of resuscitation care in patients with advanced cancer who suffer in-hospital cardiac arrest (IHCA). Methods: In the Get With The Guidelines – Resuscitation registry, 47,157 adults with IHCA with and without advanced cancer (defined as the presence of metastatic or hematologic malignancy) were identified at 369 hospitals from April 2006 through June 2010. We compared rates of return of spontaneous circulation (ROSC) and survival to discharge between groups using multivariable models. We also compared duration of resuscitation effort and resuscitation quality measures. Results: Overall, 6,585 patients with IHCA (14.0%) had advanced cancer. Patients with advanced cancer had lower multivariable-adjusted rates of ROSC (52.3% [95% CI, 49.5% to 55.3%] v 56.6% [95% CI, 53.8% to 59.5%]; P < .001) and survival to discharge (7.4% [95% CI, 6.6% to 8.4%] v 13.4% [95% CI, 12.1% to 14.8%]; P < .001). Among nonsurvivors who died during resuscitation, patients with advanced cancer had better performance on most resuscitation quality measures. Among patients with ROSC, patients with advanced cancer were made Do Not Attempt Resuscitation (DNAR) more frequently within 48 hours (adjusted relative risk, 1.30 [95% CI, 1.24 to 1.37]; P < .001). Adjustment for DNAR status explained some of the immediate effect of advanced cancer on survival; however, survival remained significantly lower in patients with cancer. Conclusion: Patients with advanced cancer can expect lower survival rates after IHCA compared with those without advanced cancer, and they are more frequently made DNAR within 48 hours of ROSC. These findings have important implications for discussions of resuscitation care wishes with patients and can better inform end-of-life discussions.

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Abstract 237: Comparative Efficacy of Biphasic Waveform Defibrillation Energies for In-Hospital Cardiac Arrest: Insights from the Get With The Guidelines--Resuscitation Registry

Circulation ◽

10.1161/circ.130.suppl_2.237 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Preston M Schneider ◽

Wenhui Liu ◽

Gary K Grunwald ◽

Paul S Chan ◽

Brahmajee K Nallamothu ◽

...

Keyword(s):

Cardiac Arrest ◽

Primary Outcome ◽

Energy Levels ◽

Spontaneous Circulation ◽

Hierarchical Regression ◽

Shock Energy ◽

Biphasic Waveform ◽

Get With The Guidelines ◽

Adjusted Association ◽

Hospital Cardiac Arrest

Background: Biphasic waveforms have become the predominant choice for defibrillation of cardiac arrest due to pulseless ventricular tachycardia or ventricular fibrillation (VT/VF). However, little is known about the relative efficacy of different first shock energy levels for defibrillation of VT/VF. Methods: Within the Get With The Guidelines - Resuscitation multicenter observational registry, we identified adults who received biphasic waveform defibrillation for in-hospital cardiac arrest due to VT/VF between 2005 and 2012. Using hierarchical regression to adjust for patient arrest characteristics and comorbidities while accounting for clustered observations by hospital, we examined the risk-adjusted association between the energy level (100J, 120J, 150J, 200J, 300J, or 360J) of the first defibrillation attempt and patient outcomes. Our primary outcome was termination of VT/VF following the first shock, with secondary outcomes of return of spontaneous circulation (ROSC), 24 hour survival, and survival to discharge. Results: Among 12,417 adults suffering VT/VF arrest treated with biphasic defibrillation, the most common first shock energy was 200 J (55.5%) Compared with 200 J, defibrillation with 120 J was more likely to result in termination of VT/VF and 24 hour survival and 150J was associated with greater 24 hour survival and survival to discharge. In contrast, energies higher than 200 J showed no difference in termination of VT/VF, but were associated with lower survival (see Table). Conclusion: Among adults with in-hospital cardiac arrest due to VT/VF, defibrillation with 200 J is the most common energy used for initial defibrillation with a biphasic waveform. However, initial defibrillation with lower energy levels is associated with greater odds of VT/VF termination, 24 hour survival, and survival to discharge. Further study is needed to inform the optimal energy for initial defibrillation of cardiac arrest due to VT/VF.

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Characteristics and Outcomes of In-Hospital Cardiac Arrest Events During the COVID-19 Pandemic

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.120.007303 ◽

2020 ◽

Vol 13 (11) ◽

Cited By ~ 1

Author(s):

Jeremy A. Miles ◽

Mateo Mejia ◽

Saul Rios ◽

Seth I. Sokol ◽

Matthew Langston ◽

...

Keyword(s):

Cardiac Arrest ◽

Intensive Care ◽

Median Time ◽

Survival Rates ◽

General Medicine ◽

Baseline Characteristics ◽

Time Periods ◽

Get With The Guidelines ◽

Hospital Cardiac Arrest ◽

Resuscitation Registry

Background: Patients hospitalized for severe coronavirus disease 2019 (COVID-19) infection are at risk for in-hospital cardiac arrest (IHCA). It is unknown whether certain characteristics of cardiac arrest care and outcomes of IHCAs during the COVID-19 pandemic differed compared with a pre-COVID-19 period. Methods: All patients who experienced an IHCA at our hospital from March 1, 2020 through May 15, 2020, during the peak of the COVID-19 pandemic, and those who had an IHCA from January 1, 2019 to December 31, 2019 were identified. All patient data were extracted from our hospital’s Get With The Guidelines–Resuscitation registry, a prospective hospital-based archive of IHCA data. Baseline characteristics of patients, interventions, and overall outcomes of IHCAs during the COVID-19 pandemic were compared with IHCAs in 2019, before the COVID-19 pandemic. Results: There were 125 IHCAs during a 2.5-month period at our hospital during the peak of the COVID-19 pandemic compared with 117 IHCAs in all of 2019. IHCAs during the COVID-19 pandemic occurred more often on general medicine wards than in intensive care units (46% versus 33%; 19% versus 60% in 2019; P <0.001), were overall shorter in duration (median time of 11 minutes [8.5–26.5] versus 15 minutes [7.0–20.0], P =0.001), led to fewer endotracheal intubations (52% versus 85%, P <0.001), and had overall worse survival rates (3% versus 13%; P =0.007) compared with IHCAs before the COVID-19 pandemic. Conclusions: Patients who experienced an IHCA during the COVID-19 pandemic had overall worse survival compared with those who had an IHCA before the COVID-19 pandemic. Our findings highlight important differences between these 2 time periods. Further study is needed on cardiac arrest care in patients with COVID-19.

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