Elsevier

Resuscitation

Volume 157, December 2020, Pages 156-165
Resuscitation

Review
The effect of system performance improvement on patients with cardiac arrest: A systematic review

https://doi.org/10.1016/j.resuscitation.2020.10.024Get rights and content

Abstract

Aim

The aim of our review was to understand the effect of interventions to improve system-level performance on the clinical outcomes of patients with cardiac arrest.

Methods

We searched PubMed, Ovid EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify randomised controlled trials and non-randomised studies published before July 21, 2020 reporting systems interventions to improve outcomes. Characteristics, study design, evaluation methods and outcomes of included studies were extracted. (PROSPERO registration CRD42020161882).

Results

One cluster randomised trial and 26 non-randomised studies were included. There were 18 studies focusing on interventions for patients with out-of-hospital cardiac arrest and 9 studies for patients with in-hospital cardiac arrest. Interventions included implementation of a bundle of care strategy, evaluation of cardiopulmonary resuscitation (CPR) quality with feedback/debriefing, data surveillance, and CPR training programs. Although improved survival with favorable neurologic outcome at discharge after the implementation of specific interventions was found in 13 studies, improved survival to hospital discharge in 14 studies and improved survival to admission in 3 studies, there were still 7 studies showing no significant improvement of clinical outcomes after interventions.

Conclusion

Although only moderate to very low certainty of evidence exists to support the effect of system-level performance improvement on the clinical outcomes of patients, we recommend that organisations or communities evaluate their performance and target key areas with the goal to improve performance because of no known risks and the potential for a large beneficial effect.

Introduction

Sudden cardiac arrest, referred to as cessation of cardiac activity with hemodynamic collapse, causes high mortality and remains a major event which affects millions of lives worldwide.1 The clinical outcomes of patients with cardiac arrest differed around the world,2 and there is a need to improve outcomes. Therefore, interventions for patients with cardiac arrest have been proposed. However, some of them only focused on small samples of patients, ambulance stations or wards, and it might raise the question about whether these interventions remain effective when they are performed in larger areas or population.

The guideline of International Liaison Committee on Resuscitation (ILCOR) in 2015 suggested the use of performance measurement and quality improvement initiatives for treating cardiac arrest in organisations.3 After the guideline was published, further studies have identified statewide or countrywide quality improvement strategies that improved the clinical outcomes of patients.4, 5, 6, 7 It was necessary to perform an update of the evidence on the effect of system-level performance improvement on patients with cardiac arrest in form of a systematic review.

Therefore, the aim of our study was to perform an updated systematic review to identify system-level interventions that improve the outcomes of patients with cardiac arrest.

Section snippets

Eligibility criteria/outcome measures

We conducted a systematic review based on a predefined protocol (PROSPERO registration CRD42020161882) and in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.8 We included studies addressing system-level performance improvement for personnel in organisations or systems caring for patients with cardiac arrest in any setting. We defined system-level performance improvement as hospital-level, community-level or country-level improvement

Study selection

After the initial database searching, a total of 7691 records were retrieved. One additional relevant article was identified through reference tracking. We removed 1260 duplicates and excluded 6376 irrelevant articles after screening titles and abstracts, and we then reviewed the full-text of 56 potentially relevant citations. Finally, 27 papers were included in our study.4, 5, 6, 7, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 The reasons for

Discussion

Our systemic review demonstrated that implementing system-level performance improvement interventions improved the clinical outcomes of patients with cardiac arrest, especially implementation of a bundle of care strategy. For patients with OHCA, implementation of a bundle of care strategy was shown to have a higher chance of survival to discharge and discharge with favorable neurological outcomes in most of the included studies. Among 11 studies in which bundle of care strategies were

Conclusion

We found system-level performance, especially implementation of a bundle of care strategy, had beneficial effect on the clinical outcomes of patients in spite of very low evidence. Organisations or communities that treat cardiac arrest should evaluate their performance and target key areas with the goal to improve performance.

Funding

The article was supported by the Taiwan Ministry of Science and Technology (MOST 108-2314-B-002 -131). This funding source had no role in the design of this study and had not any role during its execution, analyses, interpretation of the data, or decision to submit results.

Conflicts of interest

MJH, MHM and BB are members, and FB and RG are co-chairs of the ILCOR EIT Task Force. RG is ERC Director of Education and Training.

CRediT authorship contribution statement

Ying-Chih Ko: Conceptualization, Data curation, Formal analysis, Methodology, Software, Writing - original draft. Ming-Ju Hsieh: Conceptualization, Data curation, Formal analysis, Project administration, Software, Writing - original draft. Matthew Huei-Ming Ma: Data curation, Formal analysis, Writing - review & editing. Blair Bigham: Conceptualization, Data curation, Formal analysis. Farhan Bhanji: Conceptualization, Supervision, Validation, Writing - review & editing. Robert Greif:

Acknowledgement

The following ILCOR EIT Taskforce Members are acknowledged as collaborators on this systematic review: Janet Bray, Jan Breckwoldt, Jonathan P. Duff, Kasper Glerup Lauridsen, Adam Cheng, Andrew Lockey, Elaine Gilfoyle, Taku Iwami, Deems Okamoto, Jeffrey L. Pellegrino, Koen Monsieurs; and Peter Morley and Judith Finn as members of the ILCOR Scientific Advisory Committee (SAC).

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    The authors contributed equally.

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