Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation

Outcomes of in-hospital cardiac arrest among hospitals with and without telemedicine critical care

BACKGROUND

Survival rates following in-hospital cardiac arrest (IHCA) are lower during nights and weekends (off-hours), as compared to daytime on weekdays (on-hours). Telemedicine Critical Care (TCC) may provide clinical support to improve IHCA outcomes, particularly during off-hours.

OBJECTIVE

To evaluate the association between hospital availability of TCC and IHCA survival.

METHODS

We identified 44,585 adults at 280 U.S. hospitals in the Get With The Guidelines® - Resuscitation registry who suffered IHCA in an Intensive Care Unit (ICU) or hospital ward between July 2017 and December 2019. We used 2-level hierarchical multivariable logistic regression to investigate whether TCC availability was associated with better survival, overall, and during on-hours (Monday-Friday 7:00 a.m.-10:59p.m.) vs. off-hours (Monday-Friday 11:00p.m.-6:59 a.m., and Saturday-Sunday, all day, and US national holidays).

RESULTS

14,373 (32.2%) participants suffered IHCA at hospitals with TCC, and 27,032 (60.6%) occurred in an ICU. There was no difference between TCC and non-TCC hospitals in acute resuscitation survival rate or survival to discharge rates for either IHCA occurring in the ICU (acute survival odds ratio [OR] 1.02, 95% CI 0.92-1.15; survival to discharge OR 0.94 [0.83-1.07]) or outside of the ICU (acute survival OR 1.03 [0.91-1.17]; survival to discharge OR 0.99 [0.86-1.12]. Timing of cardiac arrest did not modify the association between TCC availability and acute resuscitation survival (P =.37 for interaction) or survival to discharge (P =.39 for interaction).

CONCLUSIONS

Hospital availability of TCC was not associated with improved outcomes for in-hospital cardiac arrest.

Extracorporeal cardiopulmonary resuscitation: is it futile?

PURPOSE OF REVIEW

Extracorporeal cardiopulmonary resuscitation (ECPR) is a treatment modality used to restore end-organ perfusion in the setting of refractory cardiac arrest in patients receiving cardiopulmonary resuscitation (CPR). Despite advances in medicine, survival from cardiac arrest remains low with conventional CPR. The body of literature relating to ECPR is limited to retrospective studies and case series, with data that are inconsistent. Routine use of ECPR is not currently endorsed by the American Heart Association.

RECENT FINDINGS

In several single-center retrospective studies, ECPR was associated with a higher level of return of spontaneous circulation and survival to hospital discharge, when compared with conventional CPR. However, data from larger population-based registry studies have not reproduced these findings. Implementation of ECPR is a complex endeavor that requires specialized, multidisciplinary expertise to be successful.

SUMMARY

ECPR may be considered as an adjunct to CPR in cases of refractory cardiac arrest. The success of ECPR relies on specialized expertise, thoughtful patient selection, and timely initiation.

Outcomes of pediatric patients with COVID-19 and in-hospital cardiopulmonary resuscitation

BACKGROUND

Early studies found low survival rates for adults with COVID-19 infection and in-hospital cardiac arrest (IHCA). We evaluated the association of COVID-19 infection on survival outcomes in pediatric patients undergoing cardiopulmonary resuscitation (CPR).

METHODS

Within Get-With-The-Guidelines®-Resuscitation, we identified pediatric patients who underwent CPR for an IHCA or bradycardia with poor perfusion between March and December, 2020. We compared survival outcomes (survival to discharge and return of spontaneous circulation for ≥20 minutes [ROSC]) between patients with suspected/confirmed COVID-19 infection and non-COVID-19 patients using multivariable hierarchical regression, with hospital site as a random effect and patient and cardiac arrest variables with a significant (p < 0.05) bivariate association as fixed effects.

RESULTS

Overall, 1328 pediatric in-hospital CPR events were identified (590 IHCA, 738 bradycardia with poor perfusion), of which 46 (32 IHCA, 14 bradycardia) had suspected/confirmed COVID-19 infection. Rates of survival to discharge were similar between those with and without COVID-19 infection (39.1% vs. 44.9%; adjusted RR, 1.14 [95% CI: 0.55-2.36]), and these estimates were similar for those with IHCA and bradycardia with poor perfusion (adjusted RRs of 1.03 and 1.05; interaction p = 0.96). Rates of ROSC were also similar between pediatric patients with and without COVID-19 overall (67.4% vs. 76.9%; adjusted RR, 0.87 [0.43, 1.77]), and for the subgroups with IHCA or bradycardia requiring CPR (adjusted RRs of 0.95 and 0.86, interaction p = 0.26).

CONCLUSIONS

In a large multicenter national registry of CPR events, COVID-19 infection was not associated with lower rates of ROSC or survival to hospital discharge in pediatric patients undergoing CPR.

Incidence and outcomes of in-hospital cardiac arrest in Japan 2011-2017: a nationwide inpatient database study

Background

Although numerous studies have investigated out-of-hospital cardiac arrest, few studies have been conducted on in-hospital cardiac arrest (IHCA). Knowledge of the nationwide epidemiology of IHCA in Japan, with its super-aging society, is important to understand the current situation of IHCA and to establish evidenced-based medicine in the future. The present study aimed to determine the incidence and outcomes of IHCA and their trends in Japan.

Methods

This observational cohort study was performed using a national administrative inpatient database for more than 1600 acute-care hospitals covering about 50% of all acute-care hospital beds in Japan from April 2011 to March 2018. We defined cardiac arrest patients who received cardiopulmonary resuscitation (chest compression) during hospitalization as IHCA. We excluded out-of-hospital cardiac arrest patients from the source population. The incidence of IHCA per 1000 hospital admissions and survival to discharge rate was reported with trend analyses by calendar year 2011–2017.

Results

Among 53,871,101 hospitalized patients without out-of-hospital cardiac arrest patients in 1626 hospitals, 2,136,038 (4.0%) had cardiac arrest. Of them, 274,664 (12.9%) received cardiopulmonary resuscitation at least once during hospitalization and were identified as IHCA, and 1,861,374 (87.1%) did not receive cardiopulmonary resuscitation. The incidence of IHCA per 1000 hospital admissions was 5.1, with a significant decreasing trend from 6.1 in 2011 to 4.6 in 2017 (P for trend = 0.033). Our estimated incidence can be translated to approximately 87,000 IHCA cases in Japan each year. The percentage of IHCA patients among cardiac arrest patients was 12.9%, with a significant decreasing trend from 14.0% in 2011 to 12.2% in 2017 (P for trend = 0.006). The overall rate of survival to discharge was 12.7%, with a significant increasing trend from 10.5% in 2011 to 14.0% in 2017 (P for trend < 0.001).

Conclusions

We found substantial associations between mortality and loss of health and IHCA in Japan. The incidence of IHCA showed a decreasing trend over time, the percentage of treated cardiac arrest patients also had a decreasing trend, and the overall survival to discharge rate improved over time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-022-00601-y.

Development and application of "Special defibrillator for teaching and training"

Background

To provide an economical and practical defibrillator for first aid teaching and training, to reduce the cost of teaching and training, increase teaching and training equipment, provide trainees with more hands-on training sessions, and improve first aid capabilities.

Methods

Developing a special teaching defibrillator with the same structure and operation configuration as the clinical medical emergency defibrillator. The appearance, structure and operating accessories of the two defibrillators are the same. The difference between the defibrillator and the clinical medical emergency defibrillator are as follows: the clinical medical emergency defibrillator can be energized, and there are expensive electronic accessories and defibrillation accessories for charging and discharging in the machine. When discharging, the electrode plate has current discharged into the human body; the power plug of the “special defibrillator for teaching and training” is a fake plug. When the power is plugged in, no current enters the body and the machine. There are no expensive electronic accessories and defibrillation accessories for charging and discharging, and no current is discharged during discharge. Then compare the teaching effect of the special defibrillator for teaching and training and the clinical medical emergency defibrillator (including operation score and attitude after training).

Results

The scores of defibrillator operation in the experimental group of junior college students (87.77 ± 4.11 vs. 83.30 ± 4.56, P < 0.001) and the experimental group of undergraduate students (90.40 ± 3.67 vs. 89.12 ± 3.68, P = 0.011) were higher than those in the corresponding control group; The attitude of junior college students in the experimental group and undergraduate students in the experimental group after training was more positive than that of the corresponding control group (P < 0.05).

Conclusions

The special defibrillator for teaching and training can save the purchase cost of teaching equipment, increase teaching and training resources, and improve the trainee’s defibrillation ability, defibrillation confidence and defibrillation security.

Survival outcomes and resuscitation process measures in maternal in-hospital cardiac arrest

BACKGROUND

Maternal in-hospital cardiac arrest is a rare event with the potential for resuscitation treatment delays because of the difficulty accessing hospital obstetrical units and limited simulation training or resuscitation experience of obstetrical staff. However, it is unclear whether survival rates and processes of care differ between women with a maternal in-hospital cardiac arrest and those with a nonmaternal in-hospital cardiac arrest.

OBJECTIVE

We aimed determine whether to there are delays in process measures and differences in survival outcomes between pregnant and nonpregnant women who have in-hospital cardiac arrest.

STUDY DESIGN

Using data from 2000 to 2019 in the Get With The Guidelines-Resuscitation registry, we compared resuscitation outcomes between women aged 18 to 50 years with a maternal or nonmaternal in-hospital cardiac arrest. Using a nonparsimonious propensity score, we matched patients with a maternal in-hospital cardiac arrest to as many as 10 women with a nonmaternal in-hospital cardiac arrest. We constructed conditional logistic regression models to compare survival outcomes (survival to discharge, favorable neurologic survival [discharge cerebral performance score of 1], and return of spontaneous circulation) and processes of care (delayed defibrillation [>2 minutes] and administration of epinephrine [>5 minutes]) between women with a maternal in-hospital cardiac arrest vs those with a nonmaternal in-hospital cardiac arrest.

RESULTS

Overall, 421 women with a maternal in-hospital cardiac arrest were matched by propensity score to 2316 women with a nonmaternal in-hospital cardiac arrest. The mean age among propensity score-matched women with a maternal in-hospital cardiac arrest was 31.4 (standard deviation, 6.5) years, where 33.7% were of Black race and 86.9% had an initial nonshockable cardiac arrest rhythm. Unadjusted survival rates were higher in women with a maternal in-hospital cardiac arrest than in women with a nonmaternal in-hospital cardiac arrest: survival to discharge of 45.1% vs 26.5%, survival with cerebral performance category 1 status of 36.1% vs 17.7%, and return of spontaneous circulation of 75.8% vs 70.6%. After adjustment, there was no difference in the likelihood of survival to discharge (odds ratio, 1.19; 95% confidence interval, 0.82-1.73) or return of spontaneous circulation (odds ratio, 0.94; 95% confidence interval, 0.65-1.35) between women with a maternal in-hospital cardiac arrest and those with a nonmaternal in-hospital cardiac arrest. However, women with a maternal in-hospital cardiac arrest were more likely to have favorable neurologic survival (odds ratio, 1.57; 95% confidence interval, 1.06-2.33). Compared with women with a nonmaternal in-hospital cardiac arrest, women with a maternal in-hospital cardiac arrest had similar rates of delayed defibrillation (42.5% vs 34.4%; odds ratio, 1.14 [95% confidence interval, 0.41-3.18]; P=.31) and delayed administration of epinephrine (13.8% vs 10.6%; odds ratio, 0.96 [95% confidence interval, 0.50-1.86]; P=.09).

CONCLUSION

Although concerns have been raised about resuscitation outcomes in women with a maternal in-hospital cardiac arrest, the rates of survival and resuscitation processes of care were not worse in women with a maternal in-hospital cardiac arrest.

Comparison of Machine Learning Methods for Predicting Outcomes After In-Hospital Cardiac Arrest

OBJECTIVES

Prognostication of neurologic status among survivors of in-hospital cardiac arrests remains a challenging task for physicians. Although models such as the Cardiac Arrest Survival Post-Resuscitation In-hospital score are useful for predicting neurologic outcomes, they were developed using traditional statistical techniques. In this study, we derive and compare the performance of several machine learning models with each other and with the Cardiac Arrest Survival Post-Resuscitation In-hospital score for predicting the likelihood of favorable neurologic outcomes among survivors of resuscitation.

DESIGN

Analysis of the Get With The Guidelines-Resuscitation registry.

SETTING

Seven-hundred fifty-five hospitals participating in Get With The Guidelines-Resuscitation from January 1, 2001, to January 28, 2017.

PATIENTS

Adult in-hospital cardiac arrest survivors.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 117,674 patients in our cohort, 28,409 (24%) had a favorable neurologic outcome, as defined as survival with a Cerebral Performance Category score of less than or equal to 2 at discharge. Using patient characteristics, pre-existing conditions, prearrest interventions, and periarrest variables, we constructed logistic regression, support vector machines, random forests, gradient boosted machines, and neural network machine learning models to predict favorable neurologic outcome. Events prior to October 20, 2009, were used for model derivation, and all subsequent events were used for validation. The gradient boosted machine predicted favorable neurologic status at discharge significantly better than the Cardiac Arrest Survival Post-Resuscitation In-hospital score (C-statistic: 0.81 vs 0.73; p < 0.001) and outperformed all other machine learning models in terms of discrimination, calibration, and accuracy measures. Variables that were consistently most important for prediction across all models were duration of arrest, initial cardiac arrest rhythm, admission Cerebral Performance Category score, and age.

CONCLUSIONS

The gradient boosted machine algorithm was the most accurate for predicting favorable neurologic outcomes in in-hospital cardiac arrest survivors. Our results highlight the utility of machine learning for predicting neurologic outcomes in resuscitated patients.

In-Hospital Cardiac Arrest Survival in the United States During and After the Initial Novel Coronavirus Disease 2019 Pandemic Surge

BACKGROUND

Recent reports on challenges in resuscitation care at hospitals severely affected by the novel coronavirus disease 2019 (COVID-19) pandemic raise questions about how the pandemic affected outcomes for in-hospital cardiac arrest throughout the United States.

METHODS

Within Get With The Guidelines-Resuscitation, we conducted a retrospective cohort study to compare in-hospital cardiac arrest survival during the presurge (January 1-February 29), surge (March 1-May 15) and immediate postsurge (May 16-June 30) periods in 2020 compared to 2015 to 2019. Monthly COVID-19 mortality rates for each hospital's county were categorized, per 1 000 000 residents, as low (0-10), moderate (11-50), high (51-100), or very high (>100). Using hierarchical regression models, we compared rates of survival to discharge in 2020 versus 2015 to 2019 for each period.

RESULTS

Of 61 586 in-hospital cardiac arrests, 21 208 (4309 in 2020), 26 459 (5949 in 2020), and 13 919 (2686 in 2020) occurred in the presurge, surge, and postsurge periods, respectively. During the presurge period, 24.2% survived to discharge in 2020 versus 24.7% in 2015 to 2019 (adjusted odds ratio, 1.12 [95% CI, 1.02-1.22]). In contrast, during the surge period, 19.6% survived to discharge in 2020 versus 26.0% in 2015 to 2019 (adjusted odds ratio, 0.81 [0.75-0.88]). Lower survival was most pronounced in communities with high (28% lower survival) and very high (42% lower survival) monthly COVID-19 mortality rates (interaction P<0.001). Resuscitation times were shorter (median: 22 versus 25 minutes; P<0.001), and delayed epinephrine treatment was more prevalent (11.3% versus 9.9%; P=0.004) during the surge period. Survival was lower even when patients with confirmed/suspected COVID-19 infection were excluded from analyses. During the postsurge period, survival rates were similar in 2020 versus 2015 to 2019 (22.3% versus 25.8%; adjusted odds ratio, 0.93 [0.83-1.04]), including communities with high COVID-19 mortality (interaction P=0.16).

CONCLUSIONS

Early during the pandemic, rates of survival to discharge for IHCA decreased, even among patients without COVID-19 infection, highlighting the early impact of the COVID-19 pandemic on in-hospital resuscitation.

Neural oscillations track recovery of consciousness in acute traumatic brain injury patients

Electroencephalography (EEG), easily deployed at the bedside, is an attractive modality for deriving quantitative biomarkers of prognosis and differential diagnosis in severe brain injury and disorders of consciousness (DOC). Prior work by Schiff has identified four dynamic regimes of progressive recovery of consciousness defined by the presence or absence of thalamically‐driven EEG oscillations. These four predefined categories (ABCD model) relate, on a theoretical level, to thalamocortical integrity and, on an empirical level, to behavioral outcome in patients with cardiac arrest coma etiologies. However, whether this theory‐based stratification of patients might be useful as a diagnostic biomarker in DOC and measurably linked to thalamocortical dysfunction remains unknown. In this work, we relate the reemergence of thalamically‐driven EEG oscillations to behavioral recovery from traumatic brain injury (TBI) in a cohort of N = 38 acute patients with moderate‐to‐severe TBI and an average of 1 week of EEG recorded per patient. We analyzed an average of 3.4 hr of EEG per patient, sampled to coincide with 30‐min periods of maximal behavioral arousal. Our work tests and supports the ABCD model, showing that it outperforms a data‐driven clustering approach and may perform equally well compared to a more parsimonious categorization. Additionally, in a subset of patients (N = 11), we correlated EEG findings with functional magnetic resonance imaging (fMRI) connectivity between nodes in the mesocircuit—which has been theoretically implicated by Schiff in DOC—and report a trend‐level relationship that warrants further investigation in larger studies.

Surgical stabilization of severe chest wall injury following cardiopulmonary resuscitation

BACKGROUND

Cardiopulmonary resuscitation (CPR) contributes to significant chest wall injury similar to blunt trauma. With benefits realized for surgical stabilization of rib fractures (SSRFs) for flail injuries and severely displaced fractures following trauma, SSRF for chest wall injury following CPR could be advantageous, provided good functional and neurologic outlook. Experience is limited. We present a review of patients treated with SSRF at our institution following CPR.

METHODS

A retrospective analysis of patients undergoing SSRF following CPR was performed between 2019 and 2020. Perioperative inpatient data were collected with outpatient follow-up as able.

RESULTS

Five patients underwent SSRF over the course of the 2-year interval. All patients required invasive ventilation preoperatively or had impending respiratory. Mean age was 59 ± 12 years, with all patients being male. Inciting events for cardiac arrest included respiratory, ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, and anaphylaxis. Time to operation was 6.6 ± 3 days. Four patients demonstrated anterior flail injury pattern with or without sternal fracture, with one patient having multiple severely displaced fractures. Surgical stabilization of rib fracture was performed appropriately to restore chest wall stability. Mean intensive care unit length of stay was 9.8 ± 6.4 days and overall hospital length of stay 24.6 ± 13.2 days. Median postoperative ventilation was 2 days (range, 1-15 days) with two patients developing pneumonia and one requiring tracheostomy. There were no mortalities at 30 days. One patient expired in hospice after a prolonged hospitalization. Disposition destination was variable. No hardware complications were noted on outpatient follow-up, and all surviving patients were home.

CONCLUSION

Chest wall injuries are incurred frequently following CPR. Surgical stabilization of these injuries can be considered to promote ventilator liberation and rehabilitation. Careful patient selection is paramount, with surgery offered to those with reversible causes of arrest and good functional and neurologic outcome. Experience is early, with further investigation needed.

LEVEL OF EVIDENCE

Therapeutic, Level V.

Endotracheal Intubation Versus No Endotracheal Intubation During Cardiopulmonary Arrest in the Emergency Department

Background

There is a lack of studies addressing the short and long-term outcomes of using different airway interventions in patients with cardiopulmonary arrest in the emergency department (ED). This retrospective chart review aimed to investigate the effect of endotracheal intubation (ETI) versus no ETI during cardiopulmonary arrest in the ED on return of spontaneous circulation (ROSC) and survival to discharge.

Methodology

A total of 168 charts were reviewed from August 2017 to April 2019. Resuscitation characteristics were obtained from Utstein-style-based cardiopulmonary arrest flow sheets.

Results

Unadjusted analysis showed no difference in ROSC (45.5% in ETI vs. 54.5% in no-ETI) (p = 0.08) and survival to hospital discharge at 28 days (26.7% in ETI vs. 73.3% in non-ETI) (p = 0.07) when comparing ETI versus non-ETI airway management methods during cardiopulmonary resuscitation (CPR). After adjusting for confounding factors, our regression analysis revealed that the use of ETI is associated with lower odds of ROSC (odds ratio [OR] = 3.40, 95% confidence interval [CI] = [0.14-0.84]) and survival to hospital discharge at 28 days (OR = 0.20, 95% CI = [0.04-0.84]).

Conclusions

ETI during CPR in the ED is associated with worse ROSC and survival to hospital discharge at 28 days.

Medical futility regarding cardiopulmonary resuscitation in in-hospital cardiac arrests of adult patients: A systematic review and Meta-analysis

AIM

For some patients, survival with good neurologic function after cardiopulmonary resuscitation (CPR) is highly unlikely, thus CPR would be considered medically futile. Yet, in clinical practice, there are no well-established criteria, guidelines or measures to determine futility. We aimed to investigate how medical futility for CPR in adult patients is defined, measured, and associated with do-not-resuscitate (DNR) code status as well as to evaluate the predictive value of clinical risk scores through meta-analysis.

METHODS

We searched Embase, PubMed, CINAHL, and PsycINFO from the inception of each database up to January 22, 2021. Data were pooled using a fixed-effects model. Data collection and reporting followed the PRISMA guidelines.

RESULTS

Thirty-one studies were included in the systematic review and 11 in the meta-analysis. Medical futility defined by risk scores was associated with a significantly higher risk of in-hospital mortality (5 studies, 3102 participants with Pre-Arrest Morbidity (PAM) and Prognosis After Resuscitation (PAR) score; overall RR 3.38 [95% CI 1.92-5.97]) and poor neurologic outcome/in-hospital mortality (6 studies, 115,213 participants with Good Outcome Following Attempted Resuscitation (GO-FAR) and Prediction of Outcome for In-Hospital Cardiac Arrest (PIHCA) score; RR 6.93 [95% CI 6.43-7.47]). All showed high specificity (>90%) for identifying patients with poor outcome.

CONCLUSION

There is no international consensus and a lack of specific definitions of CPR futility in adult patients. Clinical risk scores might aid decision-making when CPR is assumed to be futile. Future studies are needed to assess their clinical value and reliability as a measure of futility regarding CPR.

Impact of the three COVID-19 surges in 2020 on in-hospital cardiac arrest survival in the United States

Background

Studies have reported lower survival for in-hospital cardiac arrest (IHCA) during the initial COVID-19 surge. Whether the pandemic reduced IHCA survival during subsequent surges and in areas with lower COVID-19 rates is unknown.

Methods

Within Get-With-The-Guidelines®-Resuscitation, we identified 22,899 and 79,736 IHCAs during March to December in 2020 and 2015–2019, respectively. Using hierarchical regression, we compared risk-adjusted rates of survival to discharge in 2020 vs. 2015–19 during five COVID-19 periods: Surge 1 (March to mid-May), post-Surge 1 (mid-May to June), Surge 2 (July to mid-August), post-Surge 2 (mid-August to mid-October), and Surge 3 (mid-October to December). Monthly COVID-19 mortality rates for each hospital’s county were categorized, per 1,000,000 residents, as very low (0–10), low (11–50), moderate (51–100), or high (>100).

Results

During each COVID-19 surge period in 2020, rates of survival to discharge for IHCA were lower, as compared with the same period in 2015–2019: Surge 1: adjusted OR: 0.81 (0.75–0.88); Surge 2: adjusted OR: 0.88 (0.79–0.97), Surge 3: adjusted OR: 0.79 (0.73–0.86). Lower survival was most pronounced at hospitals located in counties with moderate to high monthly COVID-19 mortality rates. In contrast, during the two post-surge periods, survival rates were similar in 2020 vs. 2015–2019: post-Surge 1: adjusted OR 0.93 (0.83–1.04) and post-Surge 2: adjusted OR 0.94 (0.86–1.03), even at hospitals with the highest county-level COVID-19 mortality rates.

Conclusions

During the three COVID-19 surges in the U.S. during 2020, rates of survival to discharge for IHCA dropped substantially, especially in communities with moderate to high COVID-19 mortality rates.

Epinephrine before defibrillation in patients with shockable in-hospital cardiac arrest: propensity matched analysis

OBJECTIVE

To determine the use of epinephrine (adrenaline) before defibrillation for treatment of in-hospital cardiac arrest due to a ventricular arrhythmia and examine its association with patient survival.

DESIGN

Propensity matched analysis.

SETTING

2000-18 data from 497 hospitals participating in the American Heart Association’s Get With The Guidelines-Resuscitation registry.

PARTICIPANTS

Adults aged 18 and older with an index in-hospital cardiac arrest due to an initial shockable rhythm treated with defibrillation.

INTERVENTIONS

Administration of epinephrine before first defibrillation.

MAIN OUTCOME MEASURES

Survival to discharge; favorable neurological survival, defined as survival to discharge with none, mild, or moderate neurological disability measured using cerebral performance category scores; and survival after acute resuscitation (that is, return of spontaneous circulation for &gt;20 minutes). A time dependent, propensity matched analysis was performed to adjust for confounding due to indication and evaluate the independent association of epinephrine before defibrillation with study outcomes.

RESULTS

Among 34 820 patients with an initial shockable rhythm, 7054 (20.3%) were treated with epinephrine before defibrillation, contrary to current guidelines. In comparison with participants treated with defibrillation first, participants receiving epinephrine first were less likely to have a history of myocardial infarction or heart failure, but more likely to have renal failure, sepsis, respiratory insufficiency, and receive mechanical ventilation before in-hospital cardiac arrest (standardized differences &gt;10% for all). Treatment with epinephrine before defibrillation was strongly associated with delayed defibrillation (median 4 minutes v 0 minutes). In propensity matched analysis (6569 matched pairs), epinephrine before defibrillation was associated with lower odds of survival to discharge (22.4% v 29.7%; adjusted odds ratio 0.69; 95% confidence interval 0.64 to 0.74; P&lt;0.001), favorable neurological survival (15.8% v 21.6%; 0.68; 0.61 to 0.76; P&lt;0.001) and survival after acute resuscitation (61.7% v 69.5%; 0.73; 0.67 to 0.79; P&lt;0.001). The above findings were consistent in a range of sensitivity analyses, including matching according to defibrillation time.

CONCLUSIONS

Contrary to current guidelines that prioritize immediate defibrillation for in-hospital cardiac arrest due to a shockable rhythm, one in five patients are treated with epinephrine before defibrillation. Use of epinephrine before defibrillation was associated with worse survival outcomes.

Short- and Long-Term Outcomes of Hematologic Malignancy Patients After Cardiopulmonary Resuscitation: Experience of a Large Oncology Center

Purpose

The objective of this study is to describe characteristics and short- and long-term outcomes of patients with hematologic malignancies who received cardiopulmonary resuscitation (CPR).

Methods

A retrospective review was conducted of all Code Blues at a large comprehensive cancer center. Demographic, clinical, and outcome variables were analyzed for patients with a hematologic malignancy who underwent CPR.

Results

Of 258 patients, 60.1% had leukemia. Outcomes included return of spontaneous circulation (70.2%), hospital survival (12%), and 90-day, 6-month, and 1-year survival rates of 9.8%, 8.2%, and 5.9%, respectively. Factors associated with hospital mortality included establishing a do not resuscitate order after CPR (p < .0001), location of CPR (p = .0004), cause of arrest (p = .0019), requiring vasopressors (p = .0130), mechanical ventilation (p = .0423), and acute renal failure post CPR (p = .0006). Although no difference in hospital survival between leukemia and non-leukemia patients was found, more non-leukemia patients were alive at 90 days (p = .0099), 6 months (p = .0023), and 1 year (p = .0119).

Conclusions

Factors including organ dysfunction, location of CPR, and cause of arrest are associated with hospital mortality post CPR. However, immediate survival post CPR does not seem to be affected by a diagnosis of leukemia. These data should assist health care providers with discussions regarding advance care planning and goals of care after cardiac arrest.

Association between a Multidisciplinary Team Approach and Clinical Outcomes in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation in the Emergency Department

BACKGROUND AND OBJECTIVES

Despite recent improvements in advanced life support, the overall survival rate after cardiac arrest remains low. We aimed to examine the association of a multidisciplinary team approach with clinical outcomes in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) in the emergency department (ED).

METHODS

This retrospective, single-center, observational study included 125 patients who underwent ECPR in the ED between May 2004-December 2018. In January 2014, our institution implemented a multidisciplinary extracorporeal membrane oxygenation (ECMO) team. Eligible patients were classified into pre-ECMO-team (n=65) and post-ECMO-team (n=60) groups. The primary outcome was in-hospital mortality.

RESULTS

In-hospital mortality (72.3% vs. 58.3%, p=0.102) and poor neurological outcomes (78.5% vs. 68.3%, p=0.283) did not differ significantly between the pre- and post-ECMO-team groups. However, among the 60 patients who experienced in-hospital cardiac arrest, in-hospital mortality (75.8% vs. 40.7%, p=0.006) and poor neurological outcomes (78.8% vs. 48.1%, p=0.015) significantly decreased after the multidisciplinary team formation. Multivariable logistic regression analysis showed that the multidisciplinary team approach (adjusted odds ratio, 0.20; 95% confidence interval, 0.07-0.61; p=0.005) was an independent prognostic factor for in-hospital mortality in in-hospital cardiac arrest patients.

CONCLUSIONS

A multidisciplinary team approach was associated with improved clinical outcomes in in-hospital cardiac arrest patients undergoing ECPR in the ED. These findings may help in improving the selection criteria for ECPR in the ED. Further studies to overcome the study limitations may help improving the outcomes of out-of-hospital cardiac arrest patients.

Features of Patients Receiving Extracorporeal Membrane Oxygenation Relative to Cardiogenic Shock Onset: A Single-Centre Experience

Background and Objectives: Extracorporeal membrane oxygenation (ECMO) can be helpful in patients with cardiogenic shock associated with myocardial infarction, and its early use can improve the patient survival rate. In this study, we report a mortality rate-difference analysis that examined the time and location of shock occurrence. Materials and Methods: We enrolled patients who underwent ECMO due to cardiogenic shock related to myocardial infarction and assigned them to either a pre- or post-admission shock group. The primary outcome was the 1-month mortality rate; a subgroup analysis was conducted to assess the effect of bailout ECMO. Results: Of the 113 patients enrolled, 67 (38 with pre-admission shock, 29 with post-admission shock) were analysed. Asystole was more frequently detected in the pre-admission shock group than in the post-admission group. In both groups, the commonest culprit lesion location was in the left anterior descending artery. Cardiopulmonary resuscitation was performed significantly more frequently and earlier in the pre-admission group. The 1-month mortality rate was significantly lower in the pre-admission group than in the post-admission group. Male sex and ECMO duration (≥6 days) were factors significantly related to the reduced mortality rate in the pre-admission group. In the subgroup analysis, the mortality rate was lower in patients receiving bailout ECMO than in those not receiving it; the difference was not statistically significant. Conclusions: ECMO application resulted in lower short-term mortality rate among patients with out-of-hospital cardiogenic shock onset than with in-hospital shock onset; early cardiopulmonary resuscitation and ECMO might be helpful in select patients.

Epidemiology and outcomes of infants after cardiopulmonary resuscitation in the neonatal or pediatric intensive care unit from a national registry

AIM

Cardiopulmonary resuscitation (CPR) in hospitalized infants is a relatively uncommon but high-risk event associated with mortality. The study objective was to identify factors associated with mortality and survival among infants who receive CPR in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU).

METHODS

Retrospective observational study of infants with an index CPR event in the NICU or PICU between 1/1/06 and 12/31/18 in the American Heart Association's Get With The Guidelines-Resuscitation registry. Associations between patient, event, unit, and hospital factors and the primary outcome, mortality prior to discharge, were examined using multivariable logistic regression.

RESULTS

Among 3521 infants who received CPR, 2080 (59%) died before discharge, with 25% mortality during CPR and 40% within 24 h. Mortality prior to discharge occurred in 65% and 47% of cases in the NICU and PICU, respectively. Factors most strongly independently associated with pre-discharge mortality were vasoactive agent before CPR (adjusted odds ratio (aOR): 2.77, 95% confidence interval (CI) 2.15-3.58), initial pulseless condition (aOR: 2.38, 95% CI 1.46-3.86) or development of pulselessness (aOR: 2.36, 95% CI 1.78-3.12), and NICU location compared with PICU (aOR: 3.85, 95% CI 2.86-5.19). Endotracheal intubation during CPR was associated with decreased odds of pre-discharge mortality (aOR: 0.40, 95% CI 0.33-0.49).

CONCLUSION

Infants who receive CPR in the intensive care unit experience high mortality rates; identifiable patient, event, and unit factors increase the odds of mortality. Further investigation should explore the association between unit type, resuscitation processes, and mortality.

Cardiopulmonary Resuscitation and Rescue Therapies

The history of cardiopulmonary resuscitation and the Society of Critical Care Medicine have much in common, as many of the founders of the Society of Critical Care Medicine focused on understanding and improving outcomes from cardiac arrest. We review the history, the current, and future state of cardiopulmonary resuscitation.

Advances in Cardiopulmonary Life-Support Change the Meaning of What It Means to be Resuscitated

As options for advanced cardiopulmonary support proliferate, the use of mechanical circulatory support, such as left ventricular assist device as destination therapy (LVAD-DT), is becoming increasingly commonplace. In the current case, a patient was hospitalized for complications related to his LVAD-DT requests “full code” status, despite a clinician's warning that performing chest compressions may damage the LVAD device or vascular structures leading to poor outcome. This discussion explores the ethical and legal considerations regarding a patient request for cardiopulmonary resuscitation when limited options for survival or further treatment are available.

Empirical evidence for safety of mechanical ventilation during simulated cardiopulmonary resuscitation on a physical model

BACKGROUND

Cardiac arrest is a critical event requiring adequate and timely response in order to increase a patient's chance of survival. In patients mechanically ventilated with advanced airways, cardiopulmonary resuscitation (CPR) maneuver may be simplified by keeping the ventilator on. This work assessed the response of an intensive care mechanical ventilator to CPR using a patient manikin ventilated in three conventional modes.

METHODS

Volume-controlled (VCV), pressure-controlled (PCV) and pressure regulated volume-controlled (PRVC) ventilation were applied in a thorax physical model, with or without chest compressions. The mechanical ventilator was set with inspiratory time of 1.0 s, ventilation rate of 10 breaths/min, positive end-expiratory pressure of 0 cmH₂O, FiO₂ of 1.0, target tidal volume of 600 mL and trigger level of -20 cmH₂O. Airway opening pressure and ventilatory flow signals were continuously recorded.

RESULTS

Chest compression resulted in increased airway peak pressure in all ventilation modes (p < 0.001), especially with VCV (137% in VCV, 83% in PCV, 80% in PRVC). However, these pressures were limited to levels similar to release valves in manual resuscitators (~60 cmH₂O). In pressure-controlled modes tidal/min volumes decreased (PRVC = 11%, p = 0.027 and PCV = 12%, p < 0.001), while still within the variability observed during bag-valve-mask ventilation. During VCV, variation in tidal/min volumes were not significant (p = 0.140). Respiratory rate did not change with chest compression.

CONCLUSIONS

Volume and pressure ventilation modes responded differently to chest compressions. Yet, variation in delivered volume and the measured peak pressures were within the reported for the standard bag-valve-mask system.

Validation of a French-language version of TeamSTEPPS® T-TPQ and T-TAQ questionnaires

Teamwork training and evaluation are essential to enhance safety and quality of care. The lack of the psychometric testing of the TeamSTEPPS® Teamwork Attitudes Questionnaire (T-TAQ) and Teamwork Perceptions Questionnaire (T-TPQ) across different language and cultural settings has questioned their widespread use because such attitudes and perceptions are highly subjective and context-bound. The present study aims to translate the T-TAQ and T-TPQ into the French language and validate the psychometric properties of the two questionnaires in a public health context. A forward-backward translation process, panel reviewing, and pilot testing in two rounds were followed to develop the French versions. Confirmatory factor analysis (CFA) and Cronbach's alpha were used to examine the factor structure and internal consistency, whereas two-way mixed Intraclass Correlation Coefficient (ICC) was performed to assess test-retest reliability. A total of 235 healthcare professionals in the French-speaking community of Belgium completed the T-TAQ and T-TPQ. After two to four weeks, 102 participants took part in the second round. Despite good fit indices as revealed by the CFA and Cronbach's alpha from 0.53 to 0.75 for the five dimensions of the T-TAQ and 0.76 to 0.79 for the T-TPQ, the squared correlations among the constructs were higher than the average variance extracted. Two-way mixed ICCs indicated fair to good test-retest reliability for all the five constructs of the two questionnaires, except the leadership scale of the T-TAQ. The French-language versions of the T-TAQ and T-TPQ were semantically equivalent and culturally relevant with adequate test-retest reliability as compared to the English versions. These two instruments might be used to capture the overall attitude toward teamwork and perceptions of team skills and behaviors. Yet, further research is advisable to refine the scales to establish the discriminant validity of the different dimensions and discriminative power of the instruments.

Independent Risk Factors for Sepsis-Associated Cardiac Arrest in Patients with Septic Shock

The clinical characteristics and laboratory values of patients with septic shock who experience in-hospital cardiac arrest (IHCA) have not been well studied. This study aimed to evaluate the prevalence of IHCA after admission into the emergency department and to identify the factors that increase the risk of IHCA in septic shock patients. This observational cohort study used a prospective registry of septic shock patients and was conducted at the emergency department of a university-affiliated hospital. The data of 887 adult (age ≥ 18 years) septic shock (defined using the Sepsis-3 criteria) patients who were treated with a protocol-driven resuscitation bundle therapy and were admitted to the intensive care unit between January 2010 and September 2018 were analyzed. The primary endpoint was the occurrence of sepsis-associated cardiac arrest. The patient mean age was 65 years, and 61.8% were men. Sepsis-associated cardiac arrest occurred in 25.3% of patients (n = 224). The 28-day survival rate after cardiac arrest was 6.7%. Multivariate logistic regression identified chronic pulmonary disease (odds ratio (OR) 2.06), hypertension (OR 0.48), unknown infection source (OR 1.82), a hepatobiliary infection source (OR 0.25), C-reactive protein (OR 1.03), and serum lactate level 6 h from shock (OR 1.34). Considering the high mortality rate of sepsis-associated cardiac arrest after cardiopulmonary resuscitation, appropriate monitoring is required in septic shock patients with major risk factors for IHCA.

Changes in cardiac arrest profiles after the implementation of a Rapid Response Team

OBJECTIVE

To evaluate changes in the characteristics of in-hospital cardiac arrest after the implementation of a Rapid Response Team.

METHODS

This was a prospective observational study of in-hospital cardiac arrest that occurred from January 2013 to December 2017. The exclusion criterion was in-hospital cardiac arrest in the intensive care unit, emergency room or operating room. The Rapid Response Team was implemented in July 2014 in the study hospital. Patients were classified into two groups: a Pre-Rapid Response Team (in-hospital cardiac arrest before Rapid Response Team implementation) and a Post-Rapid Response Team (in-hospital cardiac arrest after Rapid Response Team implementation). Patients were followed until hospital discharge or death.

RESULTS

We had a total of 308 cardiac arrests (64.6 ± 15.2 years, 60.3% men, 13.9% with initial shockable rhythm). There was a decrease from 4.2 to 2.5 in-hospital cardiac arrest/1000 admissions after implementation of the Rapid Response Team, and we had approximately 124 calls/1000 admissions. Pre-Rapid Response Team cardiac arrest was associated with more hypoxia (29.4 versus 14.3%; p = 0.006) and an altered respiratory rate (14.7 versus 4.2%; p = 0.004) compared with post-Rapid Response Team cardiac arrest. Cardiac arrest due to hypoxia was more common before Rapid Response Team implementation (61.2 versus 38.1%, p < 0.001). In multivariate analysis, return of spontaneous circulation was associated with shockable rhythm (OR 2.97; IC95% 1.04 - 8.43) and witnessed cardiac arrest (OR 2.52; IC95% 1.39 - 4.59) but not with Rapid Response Team implementation (OR 1.40; IC95% 0.70 - 2.81) or premonitory signs (OR 0.71; IC95% 0.39 - 1.28). In multivariate analysis, in-hospital mortality was associated with non-shockable rhythm (OR 5.34; IC95% 2.28 - 12.53) and age (OR 1.03; IC95% 1.01 - 1.05) but not with Rapid Response Team implementation (OR 0.89; IC95% 0.40 - 2.02).

CONCLUSION

Even though Rapid Response Team implementation is associated with a reduction in in-hospital cardiac arrest, it was not associated with the mortality of in-hospital cardiac arrest victims. A significant decrease in cardiac arrests due to respiratory causes was noted after Rapid Response Team implementation.

Cardiac arrest patients admitted to intensive care unit after cardiopulmonary resuscitation: a retrospective cohort study to find predictors for mortality

BACKGROUND

In-hospital cardiac arrest is a common situation in hospital settings. Therefore, healthcare providers should understand the reasons that could affect the results of cardiopulmonary resuscitation. We aimed to determine the independent predictors for poor outcomes after the return of spontaneous circulation in in-hospital cardiac arrest patients, and also look for a relationship between patient's background parameters and the status at intensive care unit.

METHODS

We did a retrospective cohort study using cardiac arrest patients admitted to the intensive care unit after successful cardiopulmonary resuscitation between 2011-2015. Patients' data were gathered from hospital database. Estimated probabilities of survival were computed using the Kaplan-Meier method. Cox proportional hazard models were used to determine associated risk factors for mortality.

RESULTS

In total, 197 cardiac arrest patients were admitted to anesthesia intensive care unit after successful cardiopulmonary resuscitation in a 4-years period. Of 197 patients, 170 (86.3%) died in intensive care unit. Median of survival days was 4 days. Comorbidity (p = 0.01), higher duration of cardiopulmonary resuscitation (p = 0.02), lower Glasgow Coma Score (p = 0.00), abnormal lactate level (p = 0.00), and abnormal mean blood pressure (p = 0.01) were the main predictors for increased mortality in cardiac arrest patients after intensive care unit admission.

CONCLUSION

The consequent clinical status of the patients is affected by the physiological state after return of spontaneous circulation. Comorbidity, higher duration of cardiopulmonary resuscitation, lower arrival Glasgow Coma Score, abnormal lactate level, and abnormal mean blood pressure were the main predictors for increased mortality in patients admitted to the intensive care unit after successful cardiopulmonary resuscitation.

Assessment of the knowledge level and experience of healthcare personnel concerning CPR and early defibrillation: an internal survey

Background

In‐hospital cardiac arrest (IHCA) is a major public health problem with significant mortality. Rapid cardiopulmonary resuscitation and early defibrillation is extremely connected to patient outcome. In this study, we aimed to assess the effects of a basic life support and defibrillation course in improving knowledge in IHCA management.

Methods

We performed a prospective observational study recruiting healthcare personnel working at Azienda Ospedaliero Universitaria Pisana, Pisa, Italy. Study consisted in the administration of two questionnaires before and after BLS-D course. The course was structured as an informative meeting and it was held according to European Resuscitation Council guidelines.

Results

78 participants completed pre- and post-course questionnaires. Only 31.9% of the participants had taken part in a BLS-D before our study. After the course, we found a significative increase in the percentage of participants that evaluated their skills adequate in IHCA management (17.9% vs 42.3%; p < 0.01) and in the correct use of defibrillator (38.8% vs 67.9% p < 0.001). However, 51.3% of respondents still consider their preparation not entirely appropriate after the course. Even more, we observed a significant increase in the number of corrected responses after the course, especially about sequence performed in case of absent vital sign, CPR maneuvers and use of defibrillator.

Conclusions

The training course resulted in significant increase in the level of knowledge about the general management of IHCA in hospital staff. Therefore, a simple intervention such as an informative meetings improved significantly the knowledge about IHCA and, consequently, can lead to a reduction of morbidity and mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02009-2.

Extracorporeal cardiopulmonary resuscitation (ECPR) survival: A quaternary center analysis

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue strategy for nonresponders to conventional CPR (CCPR) in cardiac arrest. Definitive guidelines for ECPR deployment do not exist. Prior studies suggest that arrest rhythm and cardiac origin of arrest may be variables used to assess candidacy for ECPR.

AIM

To describe a single-center experience with ECPR and to assess associations between survival and physician-adjudicated origin of arrest and arrest rhythm.

METHODS

A retrospective review of all patients who underwent ECPR at a quaternary care center over a 7-year period was performed. Demographic and clinical characteristics were extracted from the medical record and used to adjudicate the origin of cardiac arrest, etiology, rhythm, survival, and outcomes. Univariate analysis was performed to determine the association of patient and arrest characteristics with survival.

RESULTS

Between 2010 and 2017, 47 cardiac arrest patients were initiated on extracorporeal membrane oxygenation (ECMO) at the time of active CPR. ECPR patient survival to hospital discharge was 25.5% (n = 12). Twenty-six patients died on ECMO (55.3%) while nine patients (19.1%) survived decannulation but died before discharge. Neither physician-adjudicated arrest rhythm nor underlying origin were significantly associated with survival to discharge, either alone or in combination. Younger age was significantly associated with survival. Nearly all survivors experienced myocardial recovery and left the hospital with a good neurological status.

CONCLUSIONS

Arrest rhythm and etiology may be insufficient predictors of survival in ECPR utilization. Further multiinstitutional studies are needed to determine evidenced-based criteria for ECPR deployment.

Effects of the COVID-19 pandemic on out-of-hospital cardiac arrest care in Detroit

Introduction

In response to the COVID-19 pandemic in Detroit, an earlier termination of resuscitation protocol was initiated in March 2020. To characterize pre-hospital cardiac arrest careduring COVID-19 in Detroit, we analyzed out-of-hospital cardiac arrest (OHCA) rate of ROSC (return of spontaneous circulation) and patient characteristics before and during the COVID-19 pandemic.

Methods

OHCA data was analyzed between March 10th, 2020 – April 30th, 2020 and March 10th, 2019 – April 30th, 2019. ROSC, patient demographics, arrest location, initial rhythms, bystander CPR and field termination were compared before and during the pandemic. Descriptive statistics were utilized to compare arrest characteristics between years, and the odds of achieving vs. not achieving ROSC. 2020 vs. 2019 as a predictor for ROSC was assessed with logistic regression.

Results

471 patients were included. Arrests increased to 291 during the pandemic vs. 180 in 2019 (62% increase). Age (mean difference + 6; 95% CI: +2.4 to +9.5), arrest location (nursing home OR = 2.42; 95% CI: 1.42–4.31; public place OR = 0.47; 95% CI: 0.25–0.88), BLS response (OR = 0.68; 95% CI: 0.47–0.99), and field termination of resuscitation (OR = 2.36; 95% CI: 1.36–4.07) differed significantly in 2020 compared to 2019. No significant difference was found in the confounder-adjusted odds of ROSC in 2020 vs 2019 (OR = 0.61; 95% CI: 0.34–1.11).

Conclusion

OHCA increased by 62% during COVID-19 in Detroit, without a significant change in prehospital ROSC. The rate of ROSC remained similar despite the implementation of an early termination of resuscitation protocol in response to COVID-19.

Comparison of clinical outcomes between patients with pulseless-ventricular tachycardia and ventricular fibrillation in out-of-hospital cardiac arrest

Aim

While previous studies have shown that the initial documented rhythm is associated with clinical outcomes in out-of-hospital cardiac arrest (OHCA), little is known about the difference in clinical outcomes between pulseless ventricular tachycardia (p-VT) and ventricular fibrillation (VF).

Methods

From a nationwide, prospective population-based database of OHCA from 2011 to 2015, we selected bystander-witnessed adult patients who were not treated with a public automated external defibrillator. The outcomes examined were favorable 30-day neurological survival rates, 30-day survival rates, and prehospital return of spontaneous circulation (ROSC) rates. To determine the association of the initial documented rhythm with outcome, we used a logistic regression model while adjusting for patient factors and prehospital care-related factors.

Results

A total of 19,594 bystander-witnessed OHCA patients who had a shockable rhythm were included: 454 (2.3%) were p-VT and 19,140 (97.7%) were VF. Compared to VF patients, p-VT patients were older, less likely to have a cardiogenic cause, and had shorter resuscitation-related time intervals (collapse to bystander cardiopulmonary resuscitation, collapse to emergency medical services contact, collapse to first ROSC, and first defibrillation to first ROSC). After adjustment for covariates, p-VT was associated with high favorable 30-day neurological survival rates (adjusted odds ratio [OR], 1.85; 95% confidence interval [CI], 1.30-2.64, p = 0.001), 30-day survival rates (adjusted OR, 1.41; 95% CI, 1.03-1.95, p = 0.037), and prehospital ROSC rates (adjusted OR, 1.90; 95% CI, 1.42-2.55, p < 0.001).

Conclusion

In this study, patients with p-VT as the initial documented rhythm had significantly better outcomes than those with VF.

Emergency Thrombolysis During Cardiac Arrest Due to Pulmonary Thromboembolism: Our Experience Over 6 Years

Introduction

Cardiac arrest (CA) is one of the leading causes of death worldwide. Among patients with CA, pulmonary embolism (PE) accounts for approximately 10% of all cases.

Objective

To compare the outcomes after cardiopulmonary-cerebral resuscitation (CCPR) with and without thrombolytic therapy (TT) in patients with CA secondary to PE.

Methods

We included patients older than 17 years admitted to our hospital between 2013 and 2017 with a diagnosis of CA with confirmed or highly suspected PE who received CCPR with or without TT. Measures of central tendency were used to depict the data.

Results

The study comprised 16 patients, 8 of whom received CCPR and thrombolysis with alteplase, whereas the remaining patients received CCPR without TT. The most frequent rhythm of CA in both groups was pulseless electrical activity. Return of spontaneous circulation (ROSC) occurred in 100% of patients who received TT and in 88% of non-thrombolysed patients. The mortality rate of patients who received TT and non-thrombolysed patients at 24 hours was 25% and 50%, respectively. However, at the time of hospital discharge, the mortality was the same in both groups (62%). In patients who received TT, mortality was related to sepsis and hemorrhage whereas in non-thrombolysed patients, mortality was due to myocardial dysfunction.

Conclusion

Intra-arrest thrombolysis resulted in a higher likelihood of ROSC and a higher 24-hour survival in adults with CA secondary to acute PE. Overall, the survival at hospital discharge was the same in the two groups.

Recovery from disorders of consciousness: mechanisms, prognosis and emerging therapies

Substantial progress has been made over the past two decades in detecting, predicting and promoting recovery of consciousness in patients with disorders of consciousness (DoC) caused by severe brain injuries. Advanced neuroimaging and electrophysiological techniques have revealed new insights into the biological mechanisms underlying recovery of consciousness and have enabled the identification of preserved brain networks in patients who seem unresponsive, thus raising hope for more accurate diagnosis and prognosis. Emerging evidence suggests that covert consciousness, or cognitive motor dissociation (CMD), is present in up to 15-20% of patients with DoC and that detection of CMD in the intensive care unit can predict functional recovery at 1 year post injury. Although fundamental questions remain about which patients with DoC have the potential for recovery, novel pharmacological and electrophysiological therapies have shown the potential to reactivate injured neural networks and promote re-emergence of consciousness. In this Review, we focus on mechanisms of recovery from DoC in the acute and subacute-to-chronic stages, and we discuss recent progress in detecting and predicting recovery of consciousness. We also describe the developments in pharmacological and electrophysiological therapies that are creating new opportunities to improve the lives of patients with DoC.

Association Between Hospital Resuscitation Champion and Survival for In-Hospital Cardiac Arrest

Background Although many hospitals have resuscitation champions, it is unknown if hospitals with very active physician or nonphysician champions have higher survival rates for in-hospital cardiac arrest (IHCA). Methods and Results We surveyed adult hospitals in Get With The Guidelines-Resuscitation about resuscitation practices, including about their resuscitation champion. Hospitals were categorized as having a very active physician champion, a very active nonphysician champion, or other (no champion or not very active champion). For each hospital, we calculated risk-standardized survival rates for IHCA during the period of 2016 to 2018 and categorized them into quintiles of risk-standardized survival rates. The association between a hospital's resuscitation champion type and their quintile of survival was evaluated using multivariable hierarchical proportional odds logistic regression. Overall, 192 hospitals (total of 44 477 IHCAs) comprised the study cohort. Risk-standardized survival rates for IHCA varied widely between hospitals (median: 24.7%; range: 9.2%-37.5%). Very active physician champions were present in 29 (15.1%) hospitals, 64 (33.3%) had very active nonphysician champions, and 99 (51.6%) did not have a very active champion. Compared with sites without a very active resuscitation champion, hospitals with a very active physician champion were 4 times more likely to be in a higher survival quintile, even after adjusting for resuscitation practices across hospital groups (adjusted odds ratio [OR], 3.90; 95% CI, 1.39-10.95). In contrast, there was no difference in survival between sites without very active champions and those with very active non-physician champions (adjusted OR, 1.28; 95% CI, 0.62-2.65). Conclusions The background and engagement level of a resuscitation champion is a critical factor in a hospital's survival outcomes for IHCA.

Age-related cognitive bias in in-hospital cardiac arrest

AIMS

Cognitive bias has been recognized as a potential source of medical error as it may affect clinical decision making. In this study, we explored how cognitive bias, specifically left-digit bias, may affect patient outcomes in in-hospital cardiac arrest.

METHODS

Using the Get With The Guidelines® - Resuscitation registry, we included adult patients with an in-hospital cardiac arrest from 2011 to 2019. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation, favorable neurological outcome, and duration of resuscitation. Using a regression discontinuity design, we explored whether there was a sudden change in survival at the age threshold of 80 years which would indicate left-digit bias. Additional analyses were performed at age thresholds of 60, 70, and 90 years.

RESULTS

A total of 26,784 patients were included for the primary analysis. The overall survival was 22% in this cohort. There was no discontinuity of survival below and above the age of 80 years (risk difference, 0.47%; 95%CI, -1.61% to 2.56%). Similar results were estimated for the secondary outcomes and for the age thresholds of 60, 70, and 90 years. The results were consistent in sensitivity analyses.

CONCLUSIONS

There was no indication that cognitive bias based on age affected outcomes in in-hospital cardiac arrest in these data.

A review of ECMO for cardiac arrest

Cardiac arrest is an important public health concern, affecting an estimated 356,500 people in the out-of-hospital setting and 209,000 people in the in-hospital setting each year. The causes of cardiac arrest include acute coronary syndromes, pulmonary embolism, dyskalemia, respiratory failure, hypovolemia, sepsis, and poisoning among many others. In order to tackle the enormous issue of high mortality among sufferers of cardiac arrest, ongoing research has been seeking improved treatment protocols and novel therapies. One of the mechanical devices that has been increasingly utilized for cardiac arrest is venoarterial extracorporeal membrane oxygenation (VA-ECMO). Presently there is only one published randomized controlled trial examining the use of VA-ECMO as part of cardiopulmonary resuscitation (CPR), a process referred to as extracorporeal cardiopulmonary resuscitation (ECPR). Recently there has been significant progress in providing ECPR for refractory cardiac arrest patients. This narrative review seeks to outline the use of ECPR for both in-hospital and out-of-hospital cardiac arrest, as well as provide information on the expected outcomes associated with its use.

Better Nurse Staffing Is Associated With Survival for Black Patients and Diminishes Racial Disparities in Survival After In-Hospital Cardiac Arrests

BACKGROUND

Racial disparities in survival among patients who had an in-hospital cardiac arrest (IHCA) have been linked to hospital-level factors.

OBJECTIVES

To determine whether nurse staffing is associated with survival disparities after IHCA.

RESEARCH DESIGN

Cross-sectional data from (1) the American Heart Association's Get With the Guidelines-Resuscitation database; (2) the University of Pennsylvania Multi-State Nursing Care and Patient Safety Survey; and (3) The American Hospital Association annual survey. Risk-adjusted logistic regression models, which took account of the hospital and patient characteristics, were used to determine the association of nurse staffing and survival to discharge for black and white patients.

SUBJECTS

A total of 14,132 adult patients aged 18 and older between 2004 and 2010 in 75 hospitals in 4 states.

RESULTS

In models that accounted for hospital and patient characteristics, the odds of survival to discharge was lower for black patients than white patients [odds ratio (OR)=0.70; 95% confidence interval (CI), 0.61-0.82]. A significant interaction was found between race and medical-surgical nurse staffing for survival to discharge, such that each additional patient per nurse lowered the odds of survival for black patients (OR=0.92; 95% CI, 0.87-0.97) more than white patients (OR=0.97; 95% CI, 0.93-1.00).

CONCLUSIONS

Our findings suggest that disparities in IHCA survival between black and white patients may be linked to the level of medical-surgical nurse staffing in the hospitals in which they receive care and that the benefit of being admitted to hospitals with better staffing may be especially pronounced for black patients.

Rapid response system in Japanese outpatient departments based on online registry: Multicentre observational study

Aim

The rapid response system (RRS) has become well known as a patient safety system to reduce adverse in-patient events, and it is also required to respond to patients in the outpatient department. However, only few studies have reported on the RRS in the outpatient department. We analysed the current status of the RRS in the outpatient department based on a multicentre online registry in Japan.

Methods

This is a prospective multicentre observational study. Among the cases registered in the RRS online registry from January 2014 to March 2018, cases from the outpatient department, consisting of the general outpatient department, radiation department, dialysis department, endoscope department, rehabilitation department, and the surrounding areas were eligible for this study.

Results

A total of 6784 cases were registered, and 1022 cases were included. The main reason for activation was altered mental status (39.1%). Incomplete vital sign recording at activation was 67.0%, whereas body temperature (57.0%) and respiratory rate (36.4%) deficits were frequent. The most common intervention during RRS activation was fluid bolus (38.2%) and oxygen supplementation (30.9%). The general outpatient department accounted for nearly half of the activation locations. The 30-day mortality rate for the location was significantly higher in the dialysis department (P < 0.001).

Conclusions

We have reported the first study of RRSs in outpatient departments at multicentre facilities in Japan. The difference in the mortality rate for the location was clarified. Future tasks will involve clarifying the RRS outcome indicators in the outpatient department and examining the effectiveness thereof.

Racial disparities in survival outcomes following pediatric in-hospital cardiac arrest

BACKGROUND

Among adults with in-hospital cardiac arrest (IHCA), overall survival is lower in black patients compared to white patients. Data regarding racial differences in survival for pediatric IHCA are unknown.

METHODS

Using 2000-2017 data from the American Heart Association Get With the Guidelines-Resuscitation® registry, we identified children >24 h and <18 years of age with IHCA due to an initial pulseless rhythm. We used generalized estimation equation to examine the association of black race with survival to hospital discharge, return of spontaneous circulation (ROSC), and favorable neurologic outcome at discharge.

RESULTS

Overall, 2940 pediatric patients (898 black, 2042 white) at 224 hospitals with IHCA were included. The mean age was 3.0 years, 57% were male and 16% had an initial shockable rhythm. Age, sex, interventions in place at the time of arrest and cardiac arrest characteristics did not differ significantly by race. The overall survival to discharge was 36.9%, return of spontaneous circulation (ROSC) was 73%, and favorable neurologic survival was 20.8%. Although black race was associated with lower rates of ROSC compared to white patients (69.5% in blacks vs. 74.6% in whites; risk-adjusted OR 0.79, 95% CI 0.67-0.94, P = 0.016), black race was not associated with survival to discharge (34.7% in blacks vs. 37.8% in whites; risk-adjusted OR 0.96, 95% CI 0.80-1.15, P = 0.68) or favorable neurologic outcome (18.7% in blacks vs. 21.8% in whites, risk-adjusted OR 0.98, 95% CI 0.80-1.20, p = 0.85).

CONCLUSIONS

In contrast to adults, we did not find evidence for racial differences in survival outcomes following IHCA among children.

Association Between Hospital Debriefing Practices With Adherence to Resuscitation Process Measures and Outcomes for In-Hospital Cardiac Arrest

Background Identifying actionable resuscitation practices that vary across hospitals could improve adherence to process measures or outcomes after in-hospital cardiac arrest (IHCA). We sought to examine whether hospital debriefing frequency after IHCA varies across hospitals and whether hospitals which routinely perform debriefing have higher rates of process-of-care compliance or survival. Methods We conducted a nationwide survey of hospital resuscitation practices in April of 2018, which were then linked to data from the Get With The Guidelines-Resuscitation national registry for IHCA. Hospitals were categorized according to their reported frequency of debriefing immediately after IHCA; rarely (0%-20% of all IHCA cases), occasionally (21%-80%), and frequently (81%-100%). Hospital-level rates of timely defibrillation (≤2 minutes), epinephrine administration (≤5 minutes), survival to discharge, return of spontaneous circulation, and neurologically intact survival were comparted for patients with IHCA from 2015 to 2017. Results Overall, there were 193 hospitals comprising 44 477 IHCA events. Mean patient age was 65±16, 41% were females, and 68% were of White race. Across hospitals, 84 (43.5%) rarely performed debriefings immediately after an IHCA, 82 (42.5%) performed debriefing sessions occasionally, and 27 (14.0%) performed debriefing frequently. There was no association between higher reported debriefing frequency and hospital rates of timely defibrillation and epinephrine administration. Mean hospital rates of risk-standardized survival to discharge were similar across debriefing frequency groups (rarely 25.6%; occasionally 26.0%; frequently 25.2%, P=0.72), as were hospital rates of risk-adjusted return of spontaneous circulation (rarely 72.2%; occasionally 73.0%; frequently 70.0%, P=0.06) and neurologically intact survival (rarely 21.9%, occasionally 22.2%, frequently 21.1%, P=0.75). Conclusions In a large contemporary nationwide quality improvement registry, hospitals varied widely in how often they conducted debriefings immediately after IHCA. However, hospital debriefing frequency was not associated with better adherence to timely delivery of epinephrine or defibrillation or higher rates of IHCA survival.

Trends in survival and introduction of the 2010 and 2015 guidelines for adult in-hospital cardiac arrest

AIMS

To examine trends in survival from 2006 to 2018 and to assess whether the introduction of resuscitation guidelines was associated with a change in survival after adult in-hospital cardiac arrest.

METHODS

Using the Get With The Guidelines® - Resuscitation registry, we included adult patients with an in-hospital cardiac arrest between 2006 and 2018. The primary outcome was survival to hospital discharge. An interrupted time series analysis was used to compare survival before and after publication of the 2010 and 2015 resuscitation guidelines.

RESULTS

The analysis included 231,739 patients. Survival changed annually by 1.09% (95% CI, 0.74% to 1.43%; P < 0.001) from 2006 to 2010, 0.26% (95% CI, -0.11% to 0.64%; P = 0.17) from 2011 to 2015, and -0.43% (95% CI, -0.96% to 0.11%; P = 0.12) from 2016 to 2018. The survival trend was lower within the post-2010 compared to the pre-2010 period (risk difference, -0.82% per year; 95% CI, -1.35% to -0.30%; P = 0.002) and within the post-2015 compared to the pre-2015 period (risk difference, -0.69% per year; 95% CI, -1.33% to -0.04%; P = 0.04). There was no immediate change in survival after publication of the 2010 and 2015 guidelines.

CONCLUSIONS

In-hospital cardiac arrest survival increased from 2006 to 2010, after which the trend plateaued. The annual survival trend was lower following publication of the 2010 and 2015 guidelines. Research targeting in-hospital cardiac arrest as a unique entity may be necessary to improve outcomes.

Polypharmacy prior to in-hospital cardiac arrest among patients with cardiopulmonary diseases: A pilot study

Background

Patterns of medication administration prior to in-hospital cardiac arrest (I-HCA) and the potential impact of these on patient outcomes is not well-established. Accordingly, types of medications administered in the 72 h prior to I-HCA were examined in relation to initial rhythms of I-HCA and survival.

Methods

A retrospective, pilot study was conducted among 96 patients who experienced I-HCA. Clinical characteristics and treatments including medications were extracted from electronic health records. Relative risk (RR) of medications or class of medications associated with the initial rhythms of I-HCA and return of spontaneous circulation (ROSC) were calculated.

Results

Two distinct sub-groups were identified that did not survive to hospital discharge (n = 31): 1) those who received either vasopressin/desmopressin (n = 16) and 2) those who received combinations of psychotherapeutic agents with anxiolytics, sedatives, and hypnotics (n = 15) prior to I-HCA. The risk of pulseless electrical activity and asystolic arrest was high in patients who received sympathomimetic agents alone or in combination with β-Adrenergic blocking agents, (RR = 1.40, 1.41, respectively). Vasopressin and a combination of vasopressin and fentanyl were associated with risk of unsuccessful ROSC (RR = 2.50, 2.38, respectively).

Conclusions

The types of medications administered during inpatient care may serve as a surrogate marker for identifying patients at risk of specific initial rhythms of I-HCA and survival.

In Hospitals With More Nurses Who Have Baccalaureate Degrees, Better Outcomes For Patients After Cardiac Arrest

In 2010, prompted by compelling evidence that demonstrated better patient outcomes in hospitals with higher percentages of nurses with a bachelor of science in nursing (BSN), the Institute of Medicine recommended that 80 percent of the nurse workforce be qualified at that level or higher by 2020. Using data from the American Heart Association's Get With the Guidelines-Resuscitation registry (for 2013-18), RN4CAST-US hospital nurse surveys (2015-16), and the American Hospital Association (2015), we found that each 10-percentage-point increase in the hospital share of nurses with a BSN was associated with 24 percent greater odds of surviving to discharge with good cerebral performance among patients who experienced in-hospital cardiac arrest. Lower patient-to-nurse ratios on general medical and surgical units were also associated with significantly greater odds of surviving with good cerebral performance. These findings contribute to the growing body of evidence that supports policies to increase access to baccalaureate-level education and improve hospital nurse staffing.

Ten-year outcomes of extracorporeal life support for in-hospital cardiac arrest at a tertiary center

Extracorporeal cardiopulmonary resuscitation (ECPR) is controversial, given both the lack of evidence for improved outcomes and clarity on appropriate candidacy during time-sensitive cardiac arrest situations. The primary objective of our study was to identify factors predicting successful outcomes in ECPR patients.Between March 2007 and November 2018, 112 patients were placed on extracorporeal life support (ECLS) during active CPR (ECPR) at our institution. The primary outcome was survival to hospital discharge. Survivors and non-survivors were compared in terms of pre-cannulation comorbidities, laboratory values, and overall outcomes. Multivariable logistic regression was used to identify pre-cannulation predictors of in-hospital mortality. Among 112 patients, 44 (39%) patients survived to decannulation and 31 (28%) survived to hospital discharge. The median age was 60 years (IQR 45-72) with a median ECLS duration of 2.2 days (IQR 0.6-5.1). Patients who survived to discharge had lower rates of chronic kidney disease than non-survivors (19% vs. 41%, p = 0.046) and lower baseline creatinine values [median 1.2 mg/dL (IQR 0.8-1.7) vs. 1.7 (0.7-2.7), p = 0.008]. Median duration from CPR initiation to cannulation was 40 min (IQR 30-50) with no difference between survivors and non-survivors (p = 0.453). When controlling for age and CPR duration, multivariable logistic regression with pre-procedural risk factors identified pre-arrest serum creatinine as an independent predictor of mortality [OR 3.25 (95% CI 1.22-8.70), p = 0.019] and higher pre-arrest serum albumin as protective [OR 0.32 (95% CI 0.14-0.74), p = 0.007]. In our cohort, pre-arrest creatinine and albumin were independently predictive of in-hospital mortality during ECPR, while age and CPR duration were not.

Personalized Connectome Mapping to Guide Targeted Therapy and Promote Recovery of Consciousness in the Intensive Care Unit

There are currently no therapies proven to promote early recovery of consciousness in patients with severe brain injuries in the intensive care unit (ICU). For patients whose families face time-sensitive, life-or-death decisions, treatments that promote recovery of consciousness are needed to reduce the likelihood of premature withdrawal of life-sustaining therapy, facilitate autonomous self-expression, and increase access to rehabilitative care. Here, we present the Connectome-based Clinical Trial Platform (CCTP), a new paradigm for developing and testing targeted therapies that promote early recovery of consciousness in the ICU. We report the protocol for STIMPACT (Stimulant Therapy Targeted to Individualized Connectivity Maps to Promote ReACTivation of Consciousness), a CCTP-based trial in which intravenous methylphenidate will be used for targeted stimulation of dopaminergic circuits within the subcortical ascending arousal network (ClinicalTrials.gov NCT03814356). The scientific premise of the CCTP and the STIMPACT trial is that personalized brain network mapping in the ICU can identify patients whose connectomes are amenable to neuromodulation. Phase 1 of the STIMPACT trial is an open-label, safety and dose-finding study in 22 patients with disorders of consciousness caused by acute severe traumatic brain injury. Patients in Phase 1 will receive escalating daily doses (0.5-2.0 mg/kg) of intravenous methylphenidate over a 4-day period and will undergo resting-state functional magnetic resonance imaging and electroencephalography to evaluate the drug's pharmacodynamic properties. The primary outcome measure for Phase 1 relates to safety: the number of drug-related adverse events at each dose. Secondary outcome measures pertain to pharmacokinetics and pharmacodynamics: (1) time to maximal serum concentration; (2) serum half-life; (3) effect of the highest tolerated dose on resting-state functional MRI biomarkers of connectivity; and (4) effect of each dose on EEG biomarkers of cerebral cortical function. Predetermined safety and pharmacodynamic criteria must be fulfilled in Phase 1 to proceed to Phase 2A. Pharmacokinetic data from Phase 1 will also inform the study design of Phase 2A, where we will test the hypothesis that personalized connectome maps predict therapeutic responses to intravenous methylphenidate. Likewise, findings from Phase 2A will inform the design of Phase 2B, where we plan to enroll patients based on their personalized connectome maps. By selecting patients for clinical trials based on a principled, mechanistic assessment of their neuroanatomic potential for a therapeutic response, the CCTP paradigm and the STIMPACT trial have the potential to transform the therapeutic landscape in the ICU and improve outcomes for patients with severe brain injuries.

Real-time audio-visual feedback with handheld nonautomated external defibrillator devices during cardiopulmonary resuscitation for in-hospital cardiac arrest: A meta-analysis

Objective:

Restoring cardiopulmonary circulation with effective chest compression remains the cornerstone of resuscitation, yet real-time compressions may be suboptimal. This project aims to determine whether in patients with in-hospital cardiac arrest (IHCA; population), chest compressions performed with free-standing audiovisual feedback (AVF) device as compared to standard manual chest compression (comparison) results in improved outcomes, including the sustained return of spontaneous circulation (ROSC), and survival to the intensive care unit (ICU) and hospital discharge (outcomes).

Methods:

Scholarly databases and relevant bibliographies were searched, as were clinical trial registries and relevant conference proceedings to limit publication bias. Studies were not limited by date, language, or publication status. Clinical randomized controlled trials (RCT) were included that enrolled adults (age ≥ 18 years) with IHCA and assessed real-time chest compressions delivered with either the standard manual technique or with AVF from a freestanding device not linked to an automated external defibrillator (AED) or automated compressor.

Results:

Four clinical trials met inclusion criteria and were included. No ongoing trials were identified. One RCT assessed the Ambu CardioPump (Ambu Inc., Columbia, MD, USA), whereas three assessed Cardio First Angel™ (Inotech, Nubberg, Germany). No clinical RCTs compared AVF devices head-to-head. Three RCTs were multi-center. Sustained ROSC (4 studies, n = 1064) was improved with AVF use (Relative risk [RR] 1.68, 95% confidence interval [CI] 1.39–2.04), as was survival to hospital discharge (2 studies, n = 922; RR 1.78, 95% CI 1.54–2.06) and survival to hospital discharge (3 studies, n = 984; RR 1.91, 95% CI 1.62–2.25).

Conclusion:

The moderate-quality evidence suggests that chest compressions performed using a non-AED free-standing AVF device during resuscitation for IHCA improves sustained ROSC and survival to ICU and hospital discharge.

Trial Registration:

PROSPERO (CRD42020157536).

Trajectory of Risk-Standardized Survival Rates for In-Hospital Cardiac Arrest

BACKGROUND

A hospital's risk-standardized survival rate (RSSR) for in-hospital cardiac arrest has emerged as an important metric to benchmark and incentivize hospital resuscitation quality. We examined whether hospital performance on the RSSR metric was stable or dynamic year-over-year and whether low-performing hospitals were able to improve survival outcomes over time.

METHODS AND RESULTS

We used data from 84 089 adult patients with an in-hospital cardiac arrest from 166 hospitals with continuous participation in Get With The Guidelines-Resuscitation from 2012 to 2017. A 2-level hierarchical regression model was used to compute RSSRs during a baseline (2012-2013) and two follow-up periods (2014-2015 and 2016-2017). At baseline, hospitals were classified as top-, middle-, and bottom-performing if they ranked in the top 25%, middle 50%, and bottom 25%, respectively, on their RSSR metric during 2012 to 2013. We compared hospital performance on RSSR during follow-up between top, middle, and bottom-performing hospitals' at baseline. During 2012 to 2013, 42 hospitals were identified as top-performing (median RSSR, 31.7%), 82 as middle-performing (median RSSR, 24.6%), and 42 as bottom-performing (median RSSR, 18.7%). During both follow-up periods, >70% of top-performing hospitals ranked in the top 50%, a substantial proportion remained in the top 25% of RSSR during 2014 to 2015 (54.6%) and 2016 to 2017 (40.4%) follow-up periods. Likewise, nearly 75% of bottom-performing hospitals remained in the bottom 50% during both follow-up periods, with 50.0% in the bottom 25% of RSSR during 2014 to 2015 and 40.5% in the bottom 25% during 2016 to 2017. While percentile rankings were generally consistent over time at ≈45% of study hospitals, ≈1 in 5 (21.4%) bottom-performing hospitals showed large improvement in percentile rankings over time and a similar proportion (23.7%) of top-performing hospitals showed large decline in percentile rankings compared with baseline.

CONCLUSIONS

Hospital performance on RSSR during baseline period was generally consistent over 4 years of follow-up. However, 1 in 5 bottom-performing hospitals had large improvement in survival over time. Identifying care and quality improvement innovations at these sites may provide opportunities to improve in-hospital cardiac arrest care at other hospitals.

Circadian variation of in-hospital cardiac arrest

BACKGROUND

Out of hospital cardiac arrests, especially those due to ventricular tachyarrhythmias, have higher incidence in the morning. It is unknown whether in-hospital cardiac arrests follow a similar pattern.

AIM OF THE STUDY

The purpose of this study was to analyze the circadian variation of in-hospital cardiac arrest incidence.

METHODS

This retrospective review of data from the multicenter Get With The Guidelines-Resuscitation registry between 2000 and 2014 used multivariable hierarchical logistic regression analysis to examine circadian rhythm of in-hospital cardiac arrest over a 24-h cycle, stratified by initial shockable versus non-shockable rhythm.

RESULTS

Among 154,038 patients, initial rhythm was recorded as asystole or pulseless electrical activity (non-shockable) in 124,918 (81%), and ventricular fibrillation or ventricular tachycardia (shockable) in 29,120 (19%). Among non-shockable events, the highest relative proportion occurred during 0400-0759 (17.9%), followed by 0000-0359 (17.1%). For shockable rhythms the greatest relative proportion occurred between 2000-2359 (17.0%), followed by 1200-1559 (16.9%). Multivariable analysis showed that the relative risk of non-shockable compared to shockable arrest was slightly higher from midnight through 0359 (aOR 1.13; 95% CI 1.06-1.20, p < 0.001) and from 0400 through 0759 h (aOR 1.14; 95% CI 1.07-1.22, p < 0.001). Although statistically significant, the magnitude of difference in incidence by time of day was small in both groups.

CONCLUSIONS

Although small differences in the relative frequency of in-hospital cardiac arrest (both shockable and non-shockable rhythms) were noted during different time intervals, in-hospital cardiac arrest occurs with nearly equal frequency throughout the day. Our findings have important implications for hospital staffing models to ensure that quality of resuscitation care is consistent regardless of time.