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Introduction: In-hospital cardiac arrest (IHCA) affects over 200 000 patients in the US annually. Approximately 20% will survive to hospital discharge, although outcomes vary between hospitals. Debriefing has been shown to improve resuscitation quality and teamwork and has been associated with improved IHCA outcomes. All IHCA at NYU Langone Health are attended by the ALERT team, a dedicated team of critical care nurses who perform active patient surveillance and respond to acute in-hospital emergencies. IHCA debriefs at NYU Langone Health have historically been performed on paper forms but were limited by low rates of compliance. As part of an ongoing quality improvement (QI) initiative, we designed and implemented an electronic debriefing tool for use after IHCA (eDebrief). Methods: The eDebrief tool was developed by the NYU Interdisciplinary Resuscitation Committee. The tool captures cardiopulmonary resuscitation (CPR) quality metrics, teamwork and leadership, use of resuscitation equipment (mechanical CPR, advanced airway adjuncts, and ultrasound), and outcomes. ALERT team nurses received an educational session and ad hoc refresher sessions if required. Data were collected at the conclusion of the event using an electronic device (iPhone, Apple, Cupertino CA). The tool is accessible using a QR code located on every code cart. Rates of IHCA debrief post-implementation (2/13/20-06/10/21) were compared to prior years (01/01/19 - 12/31/19 and 01/01/18-12/31/19). Results: The eDebrief tool was implemented on 2/13/20. During the post-implementation phase, there were 254 IHCA at NYU Langone Health. The eDebrief form was used in 175 events (69%). The debrief rate from previous calendar years were 38% and 42% for 2019 and 2018 respectively. Use of the eDebrief form has identified three targets for ongoing quality improvement and research projects: room overcrowding (identified in 64/175 IHCAs, 37%); ultrasound use (39/175 IHCAs, 22%); and optimization of mechanical CPR. Conclusions: Use of electronic debriefing is feasible at a large academic medical center and has been associated with increased uptake of IHCA debrief. Regular debriefs at our center have identified several targets for further quality improvement and research initiatives.

Introduction: Current consensus holds that CPR must balance chest compressions and ventilation rate (VR), with a low VR being essential for venous return and cardiac output. AHA guidelines recommend a VR of 10 ventilations per minute (vpm) after advanced airway placement. We sought to examine VR adherence and its impact on end-tidal CO 2 (ETCO 2 ) and ROSC >20 minutes. Methods: This is a retrospective analysis of data from AWARE II, a multicenter prospective observational study of adult in-hospital cardiac arrest (IHCA) outcomes at 14 US and UK sites. Inclusion criteria were: 1) adult patient in CA, 2) advanced airway already in place or placed during the CA, and 3) at least one minute of VR and ETCO 2 data available after removal of the last minute of CPR in subjects achieving ROSC (due to the rise of ETCO 2 just prior to ROSC). Results: A total of 563 subjects were enrolled in the parent study. Of these, 225 had ETCO 2 and VR tracings available, and 201 had sufficient data for inclusion. Mean age was 69.3 (range 18-100), patients were 63.7% male, and 16.4% had a shockable initial rhythm. A total of 116 subjects (57.7%) achieved ROSC, which was sustained in 76 (37.8%), leading to survival to hospital discharge with favorable neurological outcomes in 9 (4.5%). Mean VR was 16.3 vpm, with 171 (85.1%) subjects being ventilated in excess of guidelines; only 16 (8.0%) subjects received 8-10 vpm. Higher VR had a weak but significant association with increased mean ETCO 2 (linear R 2 = 0.11, p < 1x10 -6 ) and sustained ROSC (OR 1.05; 95% CI: 1.01-1.11; p = 0.02). Patients with sustained ROSC had a significantly higher VR at 17.7 vpm than those without sustained ROSC at 15.6 vpm (p = 0.007). Patients receiving a VR close to AHA guidelines (6-12 vpm) had a significantly lower rate of sustained ROSC (26.1%, n = 46) than patients receiving >12 vpm (42.0%, n = 148) (OR 2.30; 95% CI: 1.08-4.89; p = 0.031 using a multivariate model including patient age, shockable initial rhythm, known cardiac disease, witnessed IHCA, and use of mechanical compressions). Conclusions: VR within AHA guidelines is rare during IHCA. However, ventilation in excess of current guidelines may increase rates of sustained ROSC, an essential predicate to survival. AHA guidelines on VR in CPR with an advanced airway may not yet be optimized.

Introduction: The COVID-19 surge at our institution required deployment of large numbers of non-intensive care unit (ICU) physicians and advanced practice providers to assist in the management of the critically ill. A 3-hour “uptraining” simulation session was offered to these providers that focused on various aspects of ICU care. Hypothesis: We hypothesized that following a 3-hour simulation session, providers would feel more comfortable in managing critically-ill patients with COVID-19. Methods: One hundred and seventy-five providers underwent a 3-hour simulation-based session focused on management of shock, acute respiratory distress syndrome, and critical care ultrasound. All participants were sent surveys to assess their comfort with various aspects of ICU care following return to their usual work environments. Results: One hundred and eight providers of 175 (62%) completed the surveys. Cardiology fellows and faculty accounted for 36% of the responders, acute care nurse practitioners (NPs) accounted for 16%, while other NPs, residents, and fellows accounted for the remainder. Prior to simulation training, 31% regularly managed patients in the ICU and 28% occasionally managed ICU patients. Following training, 71% of participants were deployed to a COVID-19 ICU as part of their workflow. Overall, 104/108 responders (96%) felt training either significantly or somewhat improved their knowledge in the management of ICU patients. Ninety-four participants (91%) felt training impacted their care of critically ill patients with COVID-19. Table 1 is a display of specific ICU skillsets taught in the session and if the participants felt better equipped to utilize what was covered post deployment. Conclusions: Simulation-based training improved provider comfort in the management of critically ill patients with COVID-19. Table 1: Participants response to “if they felt better equipped to utilize ICU skills following simulation training”

Background: Thrombosis is a major concern in respiratory infections such as influenza and now COVID-19. We investigated the magnitude and duration of risk for arterial and venous thrombosis following discharge after respiratory infections. Methods: Patients with respiratory infections were identified using the United States Nationwide Readmission Database from 2012-2014. Patients admitted with asthma or cellulitis served as comparators. Readmissions for myocardial infarction (MI) and venous thromboembolism (VTE) were evaluated at 30 to 180 days. The likelihood of a thrombotic event after hospital discharge was compared with a 30-day period prior to hospitalization using conditional logistic regression. Results: Among 5,271,068 patients discharged after a respiratory infection, 0.56% and 0.78% were readmitted within 30-days with MI and VTE, respectively. Relative to asthma and cellulitis, respiratory infection was associated with a greater age and sex-adjusted hazard of 30-day readmission for MI (adjusted HR [aHR] 1.58 [95% CI 1.52-1.64] vs. asthma; aHR 1.43 [95% CI 1.38-1.48] vs. cellulitis) and VTE (aHR 1.65 [95% CI 1.60-1.69] vs. asthma; aHR 1.45, [95% CI 1.41-1.50] vs. cellulitis). Risks of MI and VTE after respiratory infection attenuated over time, yet remained higher than asthma and cellulitis over 90 and 180 days (Figure). In a crossover-cohort analysis, the odds of MI (OR 1.68 [95% CI 1.62-1.73]) and VTE (OR 3.30 [95% 3.19-3.41]) were higher in the 30 days following discharge after respiratory infection than during the baseline period. The odds of MI (OR 2.44 [95% CI 1.95-3.05]) and VTE (OR 4.49 [95% 3.50-5.76]) at 30-days appeared highest when a viral respiratory pathogen was identified. Conclusions: Hospitalization for respiratory infection, particularly when of viral etiology, was associated with an increased risk of myocardial infarction and venous thrombosis that was highest in the first 30-days after discharge and declined over time.

Introduction: In the United States, the chance of dying in the hospital widely varies by hospital, with bottom-decile hospitals having twice the rates of risk-adjusted mortality when compared to top-decile hospitals. This suggests a need for improvement in health systems nationwide. Here, we describe the implementation of, and associated outcomes for a multi-faceted, evidence-based approach to reducing in-hospital mortality. Methods: This is a retrospective interrupted time-series conducted at a large, urban, academic health system. Specifically, we describe the implementation of the following evidence-based methods: 1) escalation of communication guidelines, 2) proactive rounding with nurse response teams, and 3) rapid response teams with dedicated staff. We then quantify the associated observed-to-expected (O:E) in-hospital mortality over a 12-year period at our main hospital, and subsequently over a 3-year period at an affiliated hospital where the same interventions were later implemented. Results: Over 12 years, 445,308 patients were discharged from our main hospital, with 3,948 (0.9%) being discharged to an acute care facility, 4,558 (1.0%) discharged to hospice, and 4,648 (1.0%) expiring in the hospital. Patients had an average age of 53.1 years (std.dev 22.8 years), with the majority being female (59.0%), non-Hispanic white (66.1%), and admitted from the outpatient setting (93.3%). From the years 2010 to 2013, there was decline in O:E mortality by 59.0% (Figure 1A). This effect was sustained from 2014-2018. At the affiliate hospital, there was a similar decline in O:E mortality after implementation of the same interventions (60.5%, Figure 1B). Conclusion: Our multi-faceted, programmatic approach was associated with over 50% reductions in in-hospital mortality that were sustained for several years after implementation, and were reproduced at an affiliated hospital.