In-hospital cardiac arrest: Is outcome related to the time of arrest?

Evaluation of the blue code system established in the health campus of a university hospital

OBJECTIVE

We report the hospital outcomes after implementing the blue code system in our hospital and health campus. We also aimed to determine factors related to mortality.

METHODS

This is a retrospective observational study of the patients who received cardiopulmonary resuscitation (CPR). All blue code calls for all age groups between March 15, 2013, and April 30, 2015 were analyzed. Logistic regression analysis was performed to find independent predictors of in-hospital mortality.

RESULTS

A total of 155 patients from the blue code calls were evaluated. Return of spontaneous circulation was achieved in 45.5% of patients, and 54.8% of the patients had died at the end of the CPR. The hospital discharge rate was 20%. Of all patients, 65% were adults with a survival rate of 7.9%, whereas pediatric patients had a 44.2% survival rate. Asystole and pulseless electrical activity were the predominant electrocardiography rhythms in 92.4% of patients. The comparison of survivors and nonsurvivors revealed that nonsurvivors were older, had more cancer as the comorbidity, had a more cardiac arrest, and sepsis as the underlying cause and had >20 min of CPR. The logistic regression analysis demonstrated the independent risk factors for mortality as arrest at a hospital ward, and sepsis as the underlying cause and being adult patient.

CONCLUSION

The performance of the blue code system should be evaluated periodically. Every effort should be made to prevent unexpected cardiac arrests and increase hospital discharge with good neurologic outcomes.

Pediatric cardiac arrest in the emergency department: Outcome is related to the time of admission

Objectives:

Nights and weekends represent a potentially high-risk time for pediatric cardiac arrest (CA) patients in emergency departments. Data regarding night or weekend arrest and its impact on outcomes is controversial. The purpose of this study was to determine the relationship between cardiopulmonary resuscitation during the various emergency department shifts and survival to discharge.

Methods:

We conducted a retrospective, observational study of patients who had visited our Emergency Department for CAs from January 2014 to December 2016. Medical records and patient characteristics of 67 children with CA were retrieved from patient admission files.

Results:

The mean age was 54.7±7.3 months and 59% were male. Rates of survival to discharge 35% (11/31) within working hours’ vs. out of working hours 3% (1/36). Among the CAs presenting to the emergency department, the survival rates were higher for working hours than for non-working hours (OR: 37.6 (2.62-539.7), p: 008). The rate of return of spontaneous circulation within working hours was higher than that of non-working hours (71% vs.19%) (p<0.001). Patients who received chest compression for more than 10 minutes had the lowest survival rate (2%) (p<0.001), whereas better outcome was associated with in-hospital CA, younger age (less than 12 months) and respiratory failure.

Conclusion:

Survival rates from pediatric CAs were significantly lower during non-working hours. Poor outcome was associated with prolonged cardiopulmonary resuscitation, out of hospital CA and older age.

Trends in Survival After In-Hospital Cardiac Arrest During Nights and Weekends

BACKGROUND

Survival after in-hospital cardiac arrest (IHCA) is lower during nights and weekends (off-hours) compared with daytime during weekdays (on-hours). As overall IHCA survival has improved over time, it remains unknown whether survival differences between on-hours and off-hours have changed.

OBJECTIVES

This study sought to examine temporal trends in survival differences between on-hours and off-hours IHCA.

METHODS

We identified 151,071 adults at 470 U.S. hospitals in the Get with the Guidelines-Resuscitation registry during 2000 to 2014. Using multivariable logistic regression with generalized estimating equations, we examined whether survival trends in IHCA differed during on-hours (Monday to Friday 7:00 am to 10:59 pm) versus off-hours (Monday to Friday 11:00 pm to 6:59 am, and Saturday to Sunday, all day).

RESULTS

Among 151,071 participants, 79,091 (52.4%) had an IHCA during off-hours. Risk-adjusted survival improved over time in both groups (on-hours: 16.0% in 2000, 25.2% in 2014; off-hours: 11.9% in 2000, 21.9% in 2014; p for trend <0.001 for both). However, there was no significant change in the survival difference over time between on-hours and off-hours, either on an absolute (p = 0.75) or a relative scale (p = 0.059). Acute resuscitation survival improved significantly in both groups (on-hours: 56.1% in 2000, 71% in 2014; off-hours: 46.9% in 2000, 68.2% in 2014; p for trend <0.001 for both) and the difference between on-hours and off-hours narrowed over time (p = 0.02 absolute scale, p < 0.001 relative scale). In contrast, although post-resuscitation survival also improved over time in both groups (p for trend < 0.001 for both), the absolute and relative difference persisted.

CONCLUSIONS

Despite an overall improvement in survival, lower survival in IHCA during off-hours compared with on-hours persists.

Operating Room Codes Redefined: A Highly Reliable Model Integrating the Core Hospital Code Team

Introduction:

Typically, multidisciplinary teams manage cardiac arrests occurring outside of the operating room (OR). This approach results in reduced morbidity. However, arrests that occur in the OR are usually managed by OR personnel alone, missing the benefits of out-of-OR hospital code teams. At our institution, there were multiple pathways to activate codes, each having different respondents, depending on time and day of the week. This improvement initiative aimed to create a reliable intraoperative emergency response system with standardized respondents and predefined roles.

Methods:

A multidisciplinary improvement team led this project at an academic pediatric hospital in California. After simulations performed in the OR (in situ), the team identified a valuable key driver—a consistent activation process that initiated standard respondents, 24 hours a day, 7 days a week. By utilizing core hospital code members routinely available outside of the OR during days, nights, and weekends, respondents were identified to augment OR personnel. Code roles were preassigned. After education, we conducted in situ simulations that included the perioperative and out-of-OR code team members. We administered a knowledge assessment to perioperative staff.

Results:

The knowledge assessment for perioperative staff (n = 52) had an average score of 96%. Review of subsequent OR codes reflects an improved initiation process and management.

Conclusions:

The process for activating the emergency response system and roles for intraoperative code respondents were standardized to ensure a predictable code response, regardless of time or day of the week. Ongoing simulations with perioperative personnel continue to optimize the process.

A comparative study of the incidence of in-hospital cardiopulmonary resuscitation on Monday-Wednesday and Thursday-Sunday: Retrospective analysis in a tertiary care hospital

Because most medical staff work from Monday-Friday, it is possible that they are relatively more fatigued and less capable of providing emergency supportive services on Thursday-Sunday (Thu-Sun) than on Monday-Wednesday (Mon-Wed). In this study, we aimed to analyze the incidence of in-hospital cardiopulmonary resuscitation (CPR) to determine if it differed between Thu-Sun and Mon-Wed.This retrospective observational study of in-hospital CPR was performed during 2012 to 2016 among inpatients at the Seoul National University Bundang Hospital. The primary outcome was the incidence of in-hospital CPR per 1000 inpatients in the Mon-Wed and Thu-Sun periods. Secondary outcomes included differences in the CPR incidence by time of day and season.In the study, 1195 cases of in-hospital CPR were included. The incidence of in-hospital CPR per 1000 inpatients was significantly higher on Thu-Sun (mean: 0.595, 95% confidence interval [CI]: 0.564-0.626) than on Mon-Wed (mean: 0.505, 95% CI: 0.474-0.536, P < .001). There were no seasonal variations in the incidence of in-hospital CPR. However, in-hospital CPR was most frequently performed between 16:00 and 24:00, and the return of spontaneous circulation (ROSC) rate was the lowest among cases that occurred between 0:00 and 8:00. In addition, the ROSC rate was lowest among female patients, patients with cardiac arrest, and after in-hospital CPR performed on a Sunday.The incidence of in-hospital CPR per 1000 inpatients was significantly higher on Thu-Sun than on Mon-Wed. No seasonal variations were observed in the incidence of in-hospital CPR, but the data suggest circadian variations and differences in ROSC rates.

Cognitive impairment after sudden cardiac arrest

Aim

To evaluate the incidence and severity of the impairment of selected cognitive functions in patients after sudden cardiac arrest (SCA) in comparison to patients after myocardial infarction without SCA and healthy subjects and to analyze the influence of sociodemographic and clinical parameters and the duration of cardiac arrest on the presence and severity of the described disorders.

Material and methods

The study group comprised 30 cardiac arrest survivors, the reference group comprised 31 survivors of myocardial infarction without cardiac arrest, and the control group comprised 30 healthy subjects. The Mini-Mental State Examination (MMSE), the Digit Span test from the Wechsler Adult Intelligence Scale, Lauretta Bender’s Visual-Motor Gestalt Test, and the Benton Visual Retention Test (BVRT) were used to assess the presence of cognitive impairment. An original questionnaire developed by the author was used for overall mental state assessment.

Results

The Bender test demonstrated a significant difference in the presence and severity of visual-motor skills between the study group and the control group, while BVRT and MMSE revealed increased incidence of cognitive impairment in the study group. The Bender and BVRT (D/D)/SS (version D, method D, scaled score) scales indicated cognitive impairment in 53.3% of these patients, while the BVRT (C/A)/SS test indicated cognitive impairment in 40%. For the reference group, the values were 32.3% and 12.9%, respectively. No correlation was found between the severity of cognitive impairment and the duration of cardiac arrest.

Conclusions

Impairment of visual-motor skills, short-term visual memory, concentration, and visual-motor coordination occurs much more frequently and is more severe in individuals after SCA than in healthy individuals. Impairment of memory trace storage and recall after delay occurs more frequently in patients after SCA than in patients after myocardial infarction without cardiac arrest and in healthy individuals. SCA duration did not have any influence on the severity of the described disorders.

The Prognosis of Cardiac Origin and Noncardiac Origin in-Hospital Cardiac Arrest Occurring during Night Shifts

Background. The survival rates of in-hospital cardiac arrests (IHCAs) are reportedly low at night, but the difference between the survival rates of cardiac origin and noncardiac origin IHCAs occurring at night remains unclear. Methods. Outcomes of IHCAs during different shifts (night, day, and evening) were compared and stratified according to the etiology (cardiac and noncardiac origin). Result. The rate of return of spontaneous circulation (ROSC) was 24.7% lower for cardiac origin IHCA and 19.4% lower for noncardiac origin IHCA in the night shift than in the other shifts. The survival rate was 8.4% lower for cardiac origin IHCA occurring during the night shift, but there was no difference for noncardiac origin IHCA. After adjusting the potential confounders, chances of ROSC (aOR: 0.3, CI: 0.15–0.63) and survival to discharge (aOR: 0.1; CI: 0.01–0.90) related to cardiac origin IHCA were lower during night shifts. Regarding noncardiac origin IHCA, chances of ROSC (aOR: 0.5, CI: 0.30–0.78) were lower in the night shift, but chances of survival to discharge (aOR: 1.3, CI: 0.43–3.69) were similar in these two groups. Conclusion. IHCA occurring at night increases mortality, and this is more apparent for cardiac origin IHCAs than for noncardiac origin IHCA.

Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study

BACKGROUND

Internationally, hospital survival is lower for patients admitted at weekends and at night. Data from the UK National Cardiac Arrest Audit (NCAA) indicate that crude hospital survival was worse after in-hospital cardiac arrest (IHCA) at night versus day, and at weekends versus weekdays, despite similar frequency of events.

OBJECTIVE

To describe IHCA demographics during three day/time periods-weekday daytime (Monday to Friday, 08:00 to 19:59), weekend daytime (Saturday and Sunday, 08:00 to 19:59) and night-time (Monday to Sunday, 20:00 to 07:59)-and to compare the associated rates of return of spontaneous circulation (ROSC) for >20 min (ROSC>20 min) and survival to hospital discharge, adjusted for risk using previously developed NCAA risk models. To consider whether any observed difference could be attributed to differences in the case mix of patients resident in hospital and/or the administered care.

METHODS

We performed a prospectively defined analysis of NCAA data from 27 700 patients aged ≥16 years receiving chest compressions and/or defibrillation and attended by a hospital-based resuscitation team in response to a resuscitation (2222) call in 146 UK acute hospitals.

RESULTS

Risk-adjusted outcomes (OR (95% CI)) were worse (p<0.001) for both weekend daytime (ROSC>20 min 0.88 (0.81 to 0.95); hospital survival 0.72 (0.64 to 0.80)), and night-time (ROSC>20 min 0.72 (0.68 to 0.76); hospital survival 0.58 (0.54 to 0.63)) compared with weekday daytime. The effects were stronger for non-shockable than shockable rhythms, but there was no significant interaction between day/time of arrest and age, or day/time of arrest and arrest location. While many daytime IHCAs involved procedures, restricting the analyses to IHCAs in medical admissions with an arrest location of ward produced results that are broadly in line with the primary analyses.

CONCLUSIONS

IHCAs attended by the hospital-based resuscitation team during nights and weekends have substantially worse outcomes than during weekday daytimes. Organisational or care differences at night and weekends, rather than patient case mix, appear to be responsible.

Age influences the predictive value of Acute Physiology and Chronic Health Evaluation II and Intensive Care National Audit and Research Centre scoring models in patients admitted to Intensive Care Units after in-hospital cardiac arrest

INTRODUCTION

Outcomes following in-hospital cardiac arrest (IHCA) are generally poor though different patient populations may benefit to different degrees from admission to Intensive Care Units (ICUs). Risk stratification algorithms may be useful in identifying patients who are most likely to benefit from ICU admission and so may aid allocation of this scarce resource. We aimed to compare the performance of the Acute Physiology and Chronic Health Evaluation II (APACHE II) and Intensive Care National Audit and Research Centre (ICNARC) scoring systems in predicting outcome following ICU admission after IHCA in younger (≤69 years) and older (≥70 years) patients.

MATERIALS AND METHODS

We performed a retrospective observational study in two adult ICUs from January 2006 to February 2010 inclusive. Patients were divided into younger (≤69 years) and older (≥70 years) patients. The primary outcome measures were acute hospital mortality and area under the curve (AUC) calculation for receiver operating characteristic (ROC) analysis.

RESULTS

Two hundred and sixty-one adult consecutive adult patients admitted following IHCA. Hospital mortality was 58.6%. ROC analysis demonstrated that ICNARC was more accurate than APACHE II in predicting acute hospital outcomes in the adult population (AUC 0.734 vs. 0.706). Both scoring systems performed weaker when predicting outcomes in younger patients compared to older patients (ICNARC AUC 0.655 vs. 0.810; APACHE II AUC 0.660 vs. 0.759).

DISCUSSION

Both APACHE II and ICNARC predict outcome well in older patients. In younger patients, their value is less clear, and so they must be used with caution.

Association of mortality with out-of-hours admission in patients with perforated peptic ulcer

BACKGROUND

Perforated peptic ulcer is a serious emergency surgical condition. The aim of the present nationwide cohort study was to evaluate the association between mortality and out-of-hours admission in patients surgically treated for perforated peptic ulcer.

METHODS

All Danish patients surgically treated for benign gastric or duodenal perforated peptic ulcer in Denmark between September 1, 2011 and August 31, 2013 were included. Patients were identified through The Danish Clinical Register of Emergency Surgery. The association between 90-day mortality and time and day of admission and surgery was assessed by crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

A total of 726 patients were included. Median age was 69.5 years (range 18.2-101.7), and 569 of the 726 patients (78.4%) had at least one coexisting disease. Adjusted ORs and 95% CIs between 90-day mortality and admission in daytime vs. nighttime and weekday vs. weekend were 1.0 (0.7-1.5) and 1.2 (0.8-1.8), respectively. Adjusted ORs with 95% CI between surgery in daytime vs. nighttime and weekday vs. weekend were 0.9 (0.6-1.3) and 1.2 (0.8-1.8), respectively. Sensitivity analysis was consistent with the primary analysis. The overall 90-day mortality rate was 25.6% (186/726).

CONCLUSION

No statistically significant adjusted association between 90-day mortality and out-of-hours admission was found in patients surgically treated for perforated peptic ulcer.

The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death

INTRODUCTION

Early warning scores (EWS) are recommended as part of the early recognition and response to patient deterioration. The Royal College of Physicians recommends the use of a National Early Warning Score (NEWS) for the routine clinical assessment of all adult patients.

METHODS

We tested the ability of NEWS to discriminate patients at risk of cardiac arrest, unanticipated intensive care unit (ICU) admission or death within 24h of a NEWS value and compared its performance to that of 33 other EWSs currently in use, using the area under the receiver-operating characteristic (AUROC) curve and a large vital signs database (n=198,755 observation sets) collected from 35,585 consecutive, completed acute medical admissions.

RESULTS

The AUROCs (95% CI) for NEWS for cardiac arrest, unanticipated ICU admission, death, and any of the outcomes, all within 24h, were 0.722 (0.685-0.759), 0.857 (0.847-0.868), 0.894 (0.887-0.902), and 0.873 (0.866-0.879), respectively. Similarly, the ranges of AUROCs (95% CI) for the other 33 EWSs were 0.611 (0.568-0.654) to 0.710 (0.675-0.745) (cardiac arrest); 0.570 (0.553-0.568) to 0.827 (0.814-0.840) (unanticipated ICU admission); 0.813 (0.802-0.824) to 0.858 (0.849-0.867) (death); and 0.736 (0.727-0.745) to 0.834 (0.826-0.842) (any outcome).

CONCLUSIONS

NEWS has a greater ability to discriminate patients at risk of the combined outcome of cardiac arrest, unanticipated ICU admission or death within 24h of a NEWS value than 33 other EWSs.

APACHE II scores as predictors of cardio pulmonary resuscitation outcome: Evidence from a tertiary care institute in a low-income country

Aim:

The aim of this study was to demonstrate that APACHE II scores can be used as a predictor of the cardio-pulmonary resuscitation (CPR) outcome in hospitalized patients.

Methods:

A retrospective chart review of patients admitted, from 2002 to 2007, at the Aga Khan University Hospital, Karachi, was done for this study. Information was collected on 738 patients, constituting all adults admitted in general ward, ICU, CICU and SCU during this time, and who had under-went cardiac arrest and received cardiopulmonary resuscitation during their stay at the hospital. Patient characteristics, intra-arrest variables such as event-witnessed, initial cardiac rhythm, pre arrest need for intubation and vasoactive drugs, duration of CPR and survival details were extracted from patient records. The APACHE II score was calculated for each patient and a descriptive analysis was done for demographic and clinical features. The primary outcome of successful CPR was categorized as survival >24 h after CPR versus survival <24 h after CPR. Multivariable logistic regression was used to assess the association between the explanatory variables and successful CPR.

Results:

Patients with APACHE II scores less than 20 had 4.6 times higher odds of survival compared to patients with a score of >35 (AOR: 4.6, 95% CI: 2.4-9.0). Also, shorter duration of CPR (AOR: 2.9, 95% CI: 1.9-4.4), evening shift (AOR: 2.1, 95% CI: 1.3-3.5) and Male patients (AOR: 0.6, 95% CI: (0.4-0.9) compared to females were other significant predictors of CPR outcome.

Conclusion:

APACHE II score, along with other patient characteristics, should be considered in clinical decisions related to CPR administration.

Rapid response systems: identification and management of the "prearrest state"

Rapid response systems (RRS) are both intuitive and supported by data, but the institution of an RRS is not a panacea for in-hospital cardiac arrest or unexpected deaths. RRS implementation should be one component of an institution-wide effort to improve patient safety that includes adequate nursing education and staffing, availability and involvement of a patient's primary caregivers, and hospital provision of sufficient resources and efficiency.

Survival after in-hospital cardiopulmonary resuscitation in a major referral center

Aim:

This study was undertaken to assess the demographics, clinical parameters and outcomes of patients undergoing cardiopulmonary resuscitation (CPR), by the code blue team at our center to compare with other centers.

Materials and Methods:

Data were collected retrospectively from all adult patients who underwent CPR at our hospital from 2007 to 2008. CPR was performed on 290 patients and it was given 313 times. Clinical outcomes of interest were survival at the end of CPR and survival at discharge from the hospital. Factors associated with survival were evaluated via binomial and chi square-tests.

Results:

Of the 290 patients included, 95 patients (30.4%) had successful CPR. However, only 35 patients (12%) were alive at discharge. The majority requiring CPR were above 60 years of age (61.7%). Males required CPR more than females. There were 125 women (43.1%) and 165 males (56.9%) aged 3 to 78 (average 59.6) years. Majority (179) of the cases (61.7%) were above 60 years of age. Regarding the various wards, 54 cases (17.3%) were in the internal medicine ward, 63 cases (20.1%) in the surgery ward, 1 case (0.3%) in the clinic, 11 cases (3.5%) in the paraclinic, 116 cases (37.1%) in the emergency (ER), 55 cases (17.5%) in the Intensive Care Unit (ICU) and Coronary Care Unit (CCU), and 13 cases (4.2%) were in other wards. Cardiac massage was done in 133 cases (42.5%), defibrillation only via electroshock 3 cases (1%), and both were used in177 cases (56.5%). The ER had the most cases of CPR. Both cardiac massage and electroshock defibrillation were needed in most cases.

Conclusion:

In-hospital CPR for cardiopulmonary arrest was associated with 30.4% success at our center at the end of CPR but only 12% were alive at discharge. Duration of CPR >10 minutes was predictive of significantly decreased survival to discharge.

Survival from in-hospital cardiac arrest in Auckland City Hospital

OBJECTIVE

To describe in-hospital resuscitation outcomes and factors associated with survival at Auckland City Hospital, New Zealand.

METHODS

The Utstein template for in-hospital cardiac arrests was used. A retrospective audit of all cardiac arrests 2004-06 determined patient demographics, resuscitation time intervals, interventions, survival and neurological outcome at 12 months. Factors associated with survival to discharge were explored with logistic regression.

RESULTS

There were 3470 in-hospital deaths. Resuscitation was attempted in 415 patients (12%), with survival to discharge 27.2%. Survival was higher in first rhythm VT/VF (52.7% vs 13.1%, χ(2) = 75.3, P < 0.001), when the arrest was 'In-Hours' (41.4% vs 17%, χ(2) = 30.1, P < 0.001) and with younger age (mean [SD] for survivors 59.4 [7.1]vs 69.1 [14] for non-survivors). These associations were independent predictors of survival after multivariate logistic regression, with OR 6.2 (95% CI 3.6-10.5), 3.1 (95% CI 1.8-5.4) and 1.04 (95% CI 1.02-1.06), respectively (all P < 0.001). Other univariate predictors of survival; cardiac arrest team on site, monitored arrest and time to CPR were not significant after multivariate logistic regression. Time intervals to arrest interventions were short. Twelve month neurological outcome was good (CPC1 or 2) in 97.1% (95% CI 91.6-99.4) of survivors.

CONCLUSIONS

Survival from cardiac arrest in our hospital compared well to similar centres and good neurological outcome was higher than reported previously. Reduced survival during the 'After-Hours' period is cause for concern, and further research into the factors underlying this is required.

Mathematical modeling for prediction of survival from resuscitation based on computerized continuous capnography: proof of concept

OBJECTIVES

The objective was to describe a new method of studying correlations between real-time end tidal carbon dioxide (ETCO(2) ) data and resuscitation outcomes.

METHODS

This was a prospective cohort study of 30 patients who underwent cardiopulmonary resuscitation (CPR) in a university hospital. Sidestream capnograph data were collected during CPR and analyzed by a mathematician blinded to patient outcome. The primary outcome measure was to determine whether a meaningful relationship could be drawn between detailed computerized ETCO(2) characteristics and the return of spontaneous circulation (ROSC). Significance testing was performed for proof-of-concept purposes only.

RESULTS

Median patient age was 74 years (interquartile range [IQR] = 60-80 years; range = 16-92 years). Events were mostly witnessed (63%), with a median call-to-arrival time of 150 seconds (IQR = 105-255 seconds; range = 60-300 seconds). The incidence of ROSC was 57% (17 of 30), and of hospital discharge 20% (six of 30). Ten minutes after intubation, patients with ROSC had higher peak ETCO(2) values (p = 0.035), larger areas under the ETCO(2) curve (p = 0.016), and rising ETCO(2) slopes versus flat or falling slopes (p = 0.016) when compared to patients without ROSC. Cumulative maxETCO(2) > 20 mm Hg at all time points measured between 5 and 10 minutes postintubation best predicted ROSC (sensitivity = 0.88; specificity = 0.77; p < 0.001). Mathematical modeling targeted toward avoiding misdiagnosis of patients with recovery potential (fixed condition, false-negative rate = 0) demonstrated that cumulative maxETCO(2) (at 5-10 minutes) > 25 mm Hg or a slope greater than 0 measured between 0 and 8 minutes correctly predicted patient outcome in 70% of cases within less than 10 minutes of intubation.

CONCLUSIONS

This preliminary study suggests that computerized ETCO(2) carries potential as a tool for early, real-time decision-making during some resuscitations.

Survival after in-hospital cardiopulmonary resuscitation

BACKGROUND

The use of postarrest variables to predict survival after discharge following in-hospital cardiopulmonary resuscitation has not been definitive. This study evaluates whether the duration of cardiopulmonary resuscitation (CPR) and other variables affect discharge rates and survival rates after discharge.

METHODS

Prospective cohort survival data and arrest variables were collected, including initial observed rhythm, duration of CPR, time of arrest, and number of arrests. Arrests on unmonitored general medical units, monitored telemetry units, and critical care units were included. Outcome measures were: survival after CPR, 24 hours post-CPR, survival to discharge, and to six months postdischarge.

RESULTS

At both discharge and six months after discharge, ventricular fibrillation and ventricular tachycardia were associated with better survival rates than other initial rhythms (P < 0.001). There were significantly higher survival rates (P < 0.001) for those receiving CPR for < or =10 minutes as compared with those receiving CPR >10 minutes. Multiple versus single arrests and monitored versus unmonitored arrests approached significance. The time of day of the arrest was not a significant factor.

CONCLUSIONS

Duration of CPR >10 minutes was predictive of significantly decreased survival to discharge and six months postdischarge. Low six-month survival rates may reflect the relatively high proportion of initial rhythms other than ventricular in the study group.

Cardiopulmonary resuscitation: outcome and its predictors among hospitalized adult patients in Pakistan

Introduction

Our aim was to study the outcomes and predictors of in-hospital cardiopulmonary resuscitation (CPR) among adult patients at a tertiary care centre in Pakistan.

Methods

We conducted a retrospective chart review of all adult patients (age ≥14 years), who underwent CPR following cardiac arrest, in a tertiary care hospital during a 5-year study period (June 1998 to June 2003). We excluded patients aged 14 years or less, those who were declared dead on arrival and patients with a “do not resuscitate” order. The 1- and 6-month follow-ups of discharged patients were also recorded.

Results

We found 383 cases of adult in-hospital cardiac arrest that underwent CPR. Pulseless electrical activity was the most common initial rhythm (50%), followed by asystole (30%) and ventricular tachycardia/fibrillation (19%). Return of spontaneous circulation was achieved in 72% of patients with 42% surviving more than 24 h, and 19% survived to discharge from hospital. On follow-up, 14% and 12% were found to be alive at 1 and 6 months, respectively. Multivariable logistic regression identified three independent predictors of better outcome (survival >24 h): non-intubated status [adjusted odds ratio (aOR):3.1, 95% confidence interval (CI):1.6–6.0], location of cardiac arrest in emergency department (aOR: 18.9, 95% CI:7.0–51.0) and shorter duration of CPR (aOR:3.3, 95% CI:1.9–5.5).

Conclusion

Outcome of CPR following in-hospital cardiac arrest in our setting is better than described in other series. Non-intubated status before arrest, cardiac arrest in the emergency department and shorter duration of CPR were independent predictors of good outcome.

Overcoming barriers to in-hospital cardiac arrest documentation

AIMS

(1) To describe the introduction of standardised cardiac arrest documentation to Auckland City Hospital, highlighting how barriers to using the Utstein template were overcome. (2) To determine the adequacy of documentation of cardiac arrest time intervals.

METHOD

A retrospective audit of cardiac arrest documentation for a 3-year period following the introduction of a standard documentation form.

RESULTS

There was an initial improvement in use of the template (29% (95%CI 22-37%) to 88% (95%CI 82-92%), p<0.001) after identification of barriers and implementation of tailored strategies. Use of the template declined (77%, 95%CI 69-84%, p=0.023) after the key facilitator left the hospital. Time interval documentation ranged from 66% (95%CI 54-77%) for tracheal intubation to 91% (95%CI 80-93%) for first dose of adrenaline (epinephrine).

CONCLUSIONS

Designated 'hands-off' senior clinicians were required for accurate documentation of time intervals. Time interval documentation was sub-optimal and further efforts are required to improve this. Transfer of ownership beyond the key facilitator was integral to sustainability of the process. Future reports of in-hospital cardiac arrest outcomes should include baseline information on the adequacy of documentation of time intervals.