• Colten Stewart, Paul S Chan, Kevin Kennedy, Morgan B Swanson, Saket Girotra, and American Heart Association’s Get With The Guidelines (GWTG) Resuscitation Investigators.
• Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.
• Crit. Care Med. 2024 Jun 1; 52 (6): 878886878-886.

ObjectivesContrary to advanced cardiac life support guidelines that recommend immediate defibrillation for shockable in-hospital cardiac arrest (IHCA), epinephrine administration before first defibrillation is common and associated with lower survival at a "patient-level." Whether this practice varies across hospitals and its association with "hospital-level" IHCA survival remains unknown. The purpose of this study was to determine hospital variation in rates of epinephrine administration before defibrillation for shockable IHCA and its association with IHCA survival.DesignObservational cohort study.SettingFive hundred thirteen hospitals participating in the Get With The Guidelines Resuscitation Registry.PatientsA total of 37,668 adult patients with IHCA due to an initial shockable rhythm from 2000 to 2019.InterventionsEpinephrine before first defibrillation.Measurements And Main ResultsUsing multivariable hierarchical regression, we examined hospital variation in epinephrine administration before first defibrillation and its association with hospital-level rates of risk-adjusted survival. The median hospital rate of epinephrine administration before defibrillation was 18.8%, with large variation across sites (range, 0-68.8%; median odds ratio: 1.54; 95% CI, 1.47-1.61). Major teaching status and annual IHCA volume were associated with hospital rate of epinephrine administration before defibrillation. Compared with hospitals with the lowest rate of epinephrine administration before defibrillation (Q1), there was a stepwise decline in risk-adjusted survival at hospitals with higher rates of epinephrine administration before defibrillation (Q1: 44.3%, Q2: 43.4%; Q3: 41.9%; Q4: 40.3%; p for trend < 0.001).ConclusionsAdministration of epinephrine before defibrillation in shockable IHCA is common and varies markedly across U.S. hospitals. Hospital rates of epinephrine administration before defibrillation were associated with a significant stepwise decrease in hospital rates of risk-adjusted survival. Efforts to prioritize immediate defibrillation for patients with shockable IHCA and avoid early epinephrine administration are urgently needed.Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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