Chan Paul S, Nichol Graham, Krumholz Harlan M, Spertus John A, Nallamothu Brahmajee K
Saint Luke's Mid-America Heart Institute, Kansas City, Missouri 64111, USA.
Arch Intern Med. 2009 Jul 27;169(14):1265-73. doi: 10.1001/archinternmed.2009.196.
Delays to defibrillation are associated with worse survival after in-hospital cardiac arrest, but the degree to which hospitals vary in defibrillation response times and hospital predictors of delays remain unknown.
Using hierarchical models, we evaluated hospital variation in rates of delayed defibrillation (>2 minutes) and its impact on survival among 7479 adult inpatients with cardiac arrests at 200 hospitals within the National Registry of Cardiopulmonary Resuscitation.
Adjusted rates of delayed defibrillation varied substantially among hospitals (range, 2.4%-50.9%), with hospital-level effects accounting for a significant amount of the total variation in defibrillation delays after adjusting for patient factors. We found a 46% greater odds of patients with identical covariates getting delayed defibrillation at one randomly selected hospital compared with another. Among traditional hospital factors evaluated, however, only bed volume (reference category: <200 beds; 200-499 beds: odds ratio [OR], 0.62 [95% confidence interval {CI}, 0.48-0.80]; >or=500 beds: OR, 0.74 [95% CI, 0.53-1.04]) and arrest location (reference category: intensive care unit; telemetry unit: OR, 1.92 [95% CI, 1.65-2.22]; nonmonitored unit: OR, 1.90 [95% CI, 1.61-2.24]) were associated with differences in rates of delayed defibrillation. Wide variation also existed in adjusted hospital rates of survival to discharge (range, 5.3%-49.6%), with higher survival among hospitals in the top-performing quartile for defibrillation time (compared with the bottom quartile: OR for top quartile, 1.41 [95% CI, 1.11-1.77]).
Rates of delayed defibrillation vary widely among hospitals but are largely unexplained by traditional hospital factors. Given its association with improved survival, future research is needed to better understand best practices in the delivery of defibrillation at top-performing hospitals.
除颤延迟与院内心脏骤停后的生存率降低相关，但各医院在除颤反应时间上的差异程度以及导致延迟的医院相关预测因素仍不明确。
我们使用分层模型，评估了美国心肺复苏国家登记处中200家医院的7479例成年心脏骤停住院患者的延迟除颤率（>2分钟）的医院差异及其对生存率的影响。
调整后的延迟除颤率在各医院之间差异很大（范围为2.4%-50.9%），在调整患者因素后，医院层面的影响在除颤延迟的总变异中占很大比例。我们发现，在一家随机选择的医院中，具有相同协变量的患者发生延迟除颤的几率比另一家医院高46%。然而，在评估的传统医院因素中，只有床位数量（参考类别：<200张床位；200-499张床位：比值比[OR]，0.62[95%置信区间{CI}，0.48-0.80]；≥500张床位：OR，0.74[95%CI，0.53-1.04]）和心脏骤停发生地点（参考类别：重症监护病房；遥测病房：OR，1.92[95%CI，1.65-2.22]；非监测病房：OR，1.90[95%CI，1.61-2.24]）与延迟除颤率的差异相关。调整后的医院出院生存率也存在很大差异（范围为5.3%-49.6%），在除颤时间表现最佳的四分位数中的医院生存率更高（与最低四分位数相比：最高四分位数的OR，1.41[95%CI，1.11-1.77]）。
各医院之间延迟除颤率差异很大，但传统医院因素在很大程度上无法解释这种差异。鉴于其与生存率提高相关，未来需要开展研究，以更好地了解表现最佳的医院在提供除颤方面的最佳做法。
