LaPar Damien J, Ghanta Ravi K, Kern John A, Crosby Ivan K, Rich Jeffrey B, Speir Alan M, Kron Irving L, Ailawadi Gorav
Department of Cardiothoracic Surgery, University of Virginia Health System, Charlottesville, Virginia.
Department of Cardiothoracic Surgery, Sentera Heart Hospital, Norfolk, Virginia.
Ann Thorac Surg. 2014 Aug;98(2):534-9; discussion 539-40. doi: 10.1016/j.athoracsur.2014.03.030. Epub 2014 May 10.
Among all postoperative complications, cardiac arrest after cardiac surgical operations has the greatest association with mortality. However, hospital variation in the ability to rescue after cardiac arrest is unknown. The purpose of this study was to characterize the impact of cardiac arrest on mortality and determine the relative impact of patient, operative, and hospital factors on failure to rescue (FTR) rates and surgical mortality after cardiac arrest.
A total of 79,582 patients underwent operations at 17 different hospitals (2001 through 2011), including 5.2% (n=4,138) with postoperative cardiac arrest. Failure to rescue was defined as mortality after cardiac arrest. Patient risk, operative features, and outcomes were compared among hospitals.
Overall FTR rate was 60% with significant variation among hospitals (range, 50% to 83%; p<0.001). Failure-to-rescue patients were slightly older, presented with increased preoperative risk, and underwent more emergent operations (all p<0.05). After risk adjustment, the variable "individual hospital" demonstrated the strongest association with likelihood for FTR (likelihood ratio=39.1; p<0.001). Overall risk-adjusted mortality, cardiac arrest, and FTR rates varied across hospitals and did not correlate. High-performing hospitals with lowest FTR rates accrued longer postoperative and intensive care unit stays after the index operation (2 to 3 days; p<0.001).
Significant hospital variation exists in cardiac surgical mortality and FTR rates after cardiac arrest. Institutional factors appear to confer the strongest influence on the likelihood for mortality after cardiac arrest compared with patient and operative factors. Identifying best practice patterns at the highest performing centers may serve to improve surgical outcomes after cardiac arrest and improve patient quality.
在所有术后并发症中，心脏外科手术后的心搏骤停与死亡率的关联最为密切。然而，心脏骤停后医院的抢救能力差异尚不清楚。本研究的目的是描述心脏骤停对死亡率的影响，并确定患者、手术和医院因素对心脏骤停后抢救失败（FTR）率和手术死亡率的相对影响。
共有79582例患者在17家不同医院接受手术（2001年至2011年），其中5.2%（n = 4138）术后发生心脏骤停。抢救失败定义为心脏骤停后的死亡。对各医院的患者风险、手术特征和结局进行比较。
总体FTR率为60%，各医院之间存在显著差异（范围为50%至83%；p<0.001）。抢救失败的患者年龄稍大，术前风险增加，且接受急诊手术的比例更高（均p<0.05）。风险调整后，“个别医院”变量与FTR可能性的关联最强（似然比 = 39.1；p<0.001）。总体风险调整后的死亡率、心脏骤停和FTR率因医院而异，且无相关性。FTR率最低的高绩效医院在索引手术后的术后和重症监护病房住院时间更长（2至3天；p<0.001）。
心脏骤停后心脏外科手术死亡率和FTR率存在显著的医院差异。与患者和手术因素相比，机构因素似乎对心脏骤停后死亡的可能性影响最大。确定最高绩效中心的最佳实践模式可能有助于改善心脏骤停后的手术结局并提高患者质量。
