Highlight
1. The Resuscitation Quality Improvement (RQI) program, designed to enhance CPR training and skill retention, was adopted by several US hospitals starting in 2019.
2. A national cohort study comparing RQI-adopting hospitals with matched controls found no significant improvement in in-hospital cardiac arrest (IHCA) survival rates or return of spontaneous circulation (ROSC) after RQI implementation.
3. Both RQI and control hospitals experienced decreases in risk-standardized survival rates over the study period, underscoring challenges in improving IHCA outcomes.
4. These findings suggest that CPR-focused training programs alone may be insufficient to enhance IHCA survival, indicating a need for multifaceted resuscitation quality strategies.
Study Background
In-hospital cardiac arrest (IHCA) remains a critical challenge in acute care medicine, with survival to hospital discharge rates historically low despite advances in resuscitation science. Effective and timely cardiopulmonary resuscitation (CPR) is a cornerstone of resuscitation efforts, and proficiency in CPR techniques directly impacts patient outcomes. However, maintaining CPR competency among healthcare providers remains difficult because skills decay relatively quickly after training. To address this, the Resuscitation Quality Improvement (RQI) program was developed as an ongoing, digitally supported training system aimed at enhancing CPR skill retention and delivery quality through frequent practice and immediate feedback. Since its introduction in 2018, RQI has been widely adopted by US hospitals with the goal of improving IHCA outcomes. Nonetheless, its real-world impact on patient survival and return of spontaneous circulation has not been comprehensively evaluated on a large scale.
Study Design and Methods
This investigation was a retrospective cohort study utilizing data from 237 hospitals participating in the Get With The Guidelines-Resuscitation (GWTG-R) registry from 2017 to 2023. The study specifically compared hospitals that adopted the RQI program with control hospitals that did not. Controls were matched to RQI hospitals based on preintervention IHCA survival risk-standardized rates (RSSR) to discharge (within 1%) and annual IHCA case volume (within 50 cases), ensuring baseline comparability.
The analysis employed hierarchical difference-in-differences models to evaluate changes in IHCA survival outcomes: survival to discharge and return of spontaneous circulation (ROSC) before and after RQI adoption. The preintervention period covered two years before RQI implementation and the postintervention period covered two years after adoption.
Primary endpoints were the risk-standardized survival rate (RSSR) to hospital discharge and ROSC following IHCA events. Adjusted odds ratios (OR) with 95% confidence intervals (CI) were calculated to assess associations between RQI adoption and outcomes.
Key Findings
A total of 18 hospitals that implemented RQI were matched to 107 control hospitals, encompassing 49,870 IHCA cases. The distribution of RQI adoption was as follows: 5 hospitals in 2019, 8 in 2020, and 5 in 2021.
For survival to hospital discharge, mean RSSR at RQI hospitals declined from 25.3% (SD 3.5%) preintervention to 21.2% (SD 3.8%) postintervention. Control hospitals also experienced a decline from 25.0% (SD 2.9%) to 21.5% (SD 4.4%). The adjusted difference-in-differences analysis showed no significant association between RQI adoption and survival improvement (adjusted OR 0.95; 95% CI 0.81–1.10; P=0.48).
Regarding ROSC, RQI hospitals had a preintervention RSSR of 73.4% (SD 5.7%) decreasing to 69.1% (SD 5.1%) postintervention, while controls decreased from 70.9% (SD 6.9%) to 69.1% (SD 7.5%). The difference-in-differences analysis found no significant benefit of RQI on ROSC rates (adjusted OR 0.98; 95% CI 0.81–1.18; P=0.85).
Overall, the study found no evidence that hospital adoption of the RQI program was associated with improved survival or ROSC outcomes after IHCA within the 2-year post-adoption period.
Expert Commentary
These results provide an important, large-scale real-world assessment of a novel CPR training program, demonstrating that enhanced training alone may not suffice to improve IHCA survival. Despite the known importance of high-quality CPR, these data imply that skill retention interventions like RQI need to be integrated within broader system-level resuscitation improvements.
Potential reasons for the lack of observed benefit include the complexity of IHCA management, where factors like timely defibrillation, post-resuscitation care, rapid recognition of cardiac arrest, and multidisciplinary team coordination also critically influence outcomes. Additionally, the decline in survival rates across both groups may reflect external influences, such as evolving patient acuity or hospital resource constraints, including those related to the COVID-19 pandemic.
Limitations of the study include its observational design, potential unmeasured confounding, and the relatively short 2-year follow-up window after RQI implementation. Further research could evaluate longer-term effects and explore combining CPR skill retention with broader quality improvement interventions.
Conclusion
In conclusion, this national cohort study concludes that hospital adoption of the Resuscitation Quality Improvement program was not associated with improved survival to discharge or return of spontaneous circulation rates after in-hospital cardiac arrest compared with matched control hospitals. These findings underscore that programs focusing solely on CPR delivery skills may be insufficient to drive meaningful improvements in IHCA outcomes. Comprehensive, system-wide resuscitation quality initiatives that incorporate CPR training alongside other critical processes are likely necessary to enhance survival.
Ongoing efforts should continue to optimize resuscitation care bundles, integrate data-driven feedback systems, and reinforce multidisciplinary teamwork to improve patient outcomes following in-hospital cardiac arrests.
Funding and Trial Registration
The study was conducted using the Get With The Guidelines-Resuscitation registry data. No specific funding details are provided in the primary publication. The study was observational with no clinical trial registration.
References
1. Chan PS, Bradley SM, Spertus JA, Fu Z, Jones P, Rolston DM, Girotra S. Resuscitation Quality Improvement Program for CPR Training and Cardiac Arrest Survival in Hospitals. JAMA Cardiol. 2026 Jul 1;11(7):624-631. PMID: 42160041.
2. Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013;128(4):417-435.
3. Nolan JP, Monsieurs KG, Bossaert L, et al. European Resuscitation Council Guidelines 2021: Resuscitation education. Resuscitation. 2021;161:388-404.