The impact of telemetry on survival of in-hospital cardiac arrests in non-critical care patients

2024 RECOVER Guidelines: Monitoring. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR

OBJECTIVE

To systematically review evidence on and devise treatment recommendations for patient monitoring before, during, and following CPR in dogs and cats, and to identify critical knowledge gaps.

DESIGN

Standardized, systematic evaluation of literature pertinent to peri-CPR monitoring following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by Evidence Evaluators, and findings were reconciled by Monitoring Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk:benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization.

SETTING

Transdisciplinary, international collaboration in university, specialty, and emergency practice.

RESULTS

Thirteen questions pertaining to hemodynamic, respiratory, and metabolic monitoring practices for identification of cardiopulmonary arrest, quality of CPR, and postcardiac arrest care were examined, and 24 treatment recommendations were formulated. Of these, 5 recommendations pertained to aspects of end-tidal CO2 (ETco2) measurement. The recommendations were founded predominantly on very low quality of evidence, with some based on expert opinion.

CONCLUSIONS

The Monitoring Domain authors continue to support initiation of chest compressions without pulse palpation. We recommend multimodal monitoring of patients at risk of cardiopulmonary arrest, at risk of re-arrest, or under general anesthesia. This report highlights the utility of ETco2 monitoring to verify correct intubation, identify return of spontaneous circulation, evaluate quality of CPR, and guide basic life support measures. Treatment recommendations further suggest intra-arrest evaluation of electrolytes (ie, potassium and calcium), as these may inform outcome-relevant interventions.

Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival

Delays in treatment of in-hospital cardiac arrests (IHCAs) are associated with worsened survival. We sought to assess the impact of a bundled intervention on IHCA survival in patients on centralised telemetry. A retrospective quality improvement study was performed of a bundled intervention which incorporated (1) a telemetry hotline for telemetry technicians to reach nursing staff; (2) empowerment of telemetry technicians to directly activate the IHCA response team and (3) a standardised escalation system for automated critical alerts within the nursing mobile phone system. In the 4-year study period, there were 75 IHCAs, including 20 preintervention and 55 postintervention. Cox proportional hazard regression predicts postintervention individuals have a 74% reduced the risk of death (HR 0.26, 95% CI 0.08 to 0.84) during a code and a 55% reduced risk of death (HR 0.45, 95% CI 0.23 to 0.89) prior to hospital discharge. Overall code survival improved from 60.0% to 83.6% (p=0.031) with an improvement in ventricular tachycardia/ventricular fibrillation (VT/VF) code survival from 50.0% to 100.0% (p=0.035). There was no difference in non-telemetry code survival preintervention and postintervention (71.4% vs 71.3%, p=0.999). The bundled intervention, including improved communication between telemetry technicians and nurses as well as empowerment of telemetry technicians to directly activate the IHCA response team, may improve IHCA survival, specifically for VT/VF arrests.

Benefit of continued noninvasive cardiac monitoring in geriatric trauma: A retrospective review of geriatric pelvis, hip, and femur fractures and analysis of cardiac events during immediate post-traumatic course

Objective

The geriatric population suffers from a predisposition to cardiac events due to physiologic changes commonly associated with aging. The majority of the trauma population seen at our facility is within the geriatric population (greater than 65 years old). Therefore, this study was aimed to determine which of those preexisting factors were associated with an increased risk for developing cardiac event. By assessing those risks, we hoped to determine a timeline for the highest risk of cardiac event occurrence, in order to identify a safe period of when cardiac monitoring was indicated.

Methods

A retrospective study performed over 6 months reviewing geriatric trauma patients with hip, pelvis, or femur fractures, n = 125. A list of predetermined risk factors including comorbidities, pathologies, laboratory values, electrocardiogram findings, and surgery was crossed with the patient's records in order to identify factors for increased risk of cardiac event. Once patients who had documented cardiac events were identified, a temporal pattern of cardiac event occurrence was analyzed in order to determine a period when noninvasive cardiac monitoring should remain in place.

Results

In 125 patients, 40 cardiac events occurred in 30 patients. The analyzed variables with statistically significant associations for having a cardiac event were comorbidities (p = 0.019), elevated body mass index (p = 0.001), abnormal initial phosphorus (p = 0.002), and an electrocardiogram finding of other than normal sinus rhythm (p = 0.020). Of the identified cardiac events, we found that by hospital day 3 68% of cardiac event had occurred, with 85% by hospital day 4, 95% by day 5, and 100% within the first 7 days of admission.

Conclusion

Patient history of cardiac comorbidities, elevated body mass index, abnormal phosphorus, and abnormal electrocardiogram findings were found to be significant risk factors for cardiac event development in geriatric trauma. All recorded events in our study occurred within 7 days of the initial trauma.

Resuscitation outcomes of a wireless ECG telemonitoring system for cardiovascular ward patients experiencing in-hospital cardiac arrest

BACKGROUND/PURPOSE

In-hospital cardiac arrest is a serious issue for hospitalized patients. The documented initial rhythm and detected medical events have been reported to influence the survival of cardiopulmonary resuscitation. This study aimed to identify the effect of continuous real-time electrocardiogram (ECG) monitoring on the prognosis of resuscitated patients in a general cardiac ward.

METHODS

We conducted this retrospective study using medical records of hospitalized patients in a cardiovascular ward who experienced an in-hospital cardiac arrest and received cardiopulmonary resuscitation from February 2015 to December 2018. The patients who were considered to be at high risk of cardiac events such as ventricular arrhythmia would receive continuous ECG monitoring. A wireless ECG telemonitoring system was introduced to replace traditional bedside ECG monitors. The outcome measures were the initial success of resuscitation, 24-h survival after resuscitation, and survival to discharge.

RESULTS

We enrolled 115 patients with a cardiac arrest during hospitalization, of whom 73 (63%) patients received wireless ECG telemonitoring. Patients receiving continuous ECG monitoring were associated with higher opportunities of initial success of resuscitation and 24-h survival after resuscitation (67.1% vs. 40.5%, p = 0.005; and 49.3% vs. 26.2%, p = 0.015, respectively) when comparing to the non-monitoring group; but no significant difference in survival to discharge (21.9% vs. 16.7%, p = 0.498) was observed. With adjustment of the covariates, the monitoring group was associated with a higher likelihood to reach the initial success of resuscitation (odds ratios [ORs], 3.21; 95% confidence interval [CI], 1.03-9.98). However, the effect of monitoring on 24-h survival and survival to discharge was close to null after adjusting for covariates.

CONCLUSION

A wireless ECG telemonitoring system were beneficial to the initial success of resuscitation for patients at high risk of cardiovascular events suffering an in-hospital cardiac arrest; but had less impact on 24-h survival and survival to discharge.

Lessons Learned from Efforts to Reduce Overuse of Cardiac Telemetry Monitoring

BACKGROUND

Inappropriate use of telemetry monitoring is common, increasing costs, false alarms, and length of stay. The Society of Hospital Medicine and Choosing Wisely encourage the use of discontinuation protocols.

METHODS

This quality improvement initiative measured the impact of an educational intervention and distribution of performance reports for physicians and residents on the general medicine service. The intervention group received a 15-minute didactic session on appropriate indications for telemetry followed by weekly performance reports for 78 weeks. A segmented linear regression model and Student's t-test were used to determine intervention effects on percentage of patients on telemetry and telemetry orders lasting more than 48 hours.

RESULTS

Prior to the intervention, 4.8% of patients received telemetry monitoring; 13.4% of telemetry orders exceeded 48 hours. The control service had a baseline telemetry utilization of 2.4%; 1.2% of telemetry orders exceeded 48 hours. After the intervention, 3.9% of patients received telemetry monitoring; 10.6% of telemetry orders exceeded 48 hours. The control service had a postintervention telemetry utilization of 2.1%; 1.1% of telemetry orders exceeded 48 hours. The Student's t-test showed a statistically significant (p = 0.002) decrease in telemetry ordering rate on the intervention service and no significant change in the control group. However, when using segmented linear regression analysis, these changes could not be attributed to the intervention nor were there any significant changes in balancing metrics.

CONCLUSION

Education and weekly performance feedback did not significantly impact telemetry according to segmented linear regression results. Segmented linear regression analysis of an interrupted time series yielded significantly different results from a pre-post comparison using Student's t-test. Rigorous evaluation is vital to decreasing unnecessary care and successful reduction in unnecessary care may require interventions that capitalize on systems-level change.

Pre-arrest and intra-arrest prognostic factors associated with survival after in-hospital cardiac arrest: systematic review and meta-analysis

OBJECTIVE

To determine associations between important pre-arrest and intra-arrest prognostic factors and survival after in-hospital cardiac arrest.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, PubMed, Embase, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception to 4 February 2019. Primary, unpublished data from the United Kingdom National Cardiac Arrest Audit database.

STUDY SELECTION CRITERIA

English language studies that investigated pre-arrest and intra-arrest prognostic factors and survival after in-hospital cardiac arrest.

DATA EXTRACTION

PROGRESS (prognosis research strategy group) recommendations and the CHARMS (critical appraisal and data extraction for systematic reviews of prediction modelling studies) checklist were followed. Risk of bias was assessed by using the QUIPS tool (quality in prognosis studies). The primary analysis pooled associations only if they were adjusted for relevant confounders. The GRADE approach (grading of recommendations assessment, development, and evaluation) was used to rate certainty in the evidence.

RESULTS

The primary analysis included 23 cohort studies. Of the pre-arrest factors, male sex (odds ratio 0.84, 95% confidence interval 0.73 to 0.95, moderate certainty), age 60 or older (0.50, 0.40 to 0.62, low certainty), active malignancy (0.57, 0.45 to 0.71, high certainty), and history of chronic kidney disease (0.56, 0.40 to 0.78, high certainty) were associated with reduced odds of survival after in-hospital cardiac arrest. Of the intra-arrest factors, witnessed arrest (2.71, 2.17 to 3.38, high certainty), monitored arrest (2.23, 1.41 to 3.52, high certainty), arrest during daytime hours (1.41, 1.20 to 1.66, high certainty), and initial shockable rhythm (5.28, 3.78 to 7.39, high certainty) were associated with increased odds of survival. Intubation during arrest (0.54, 0.42 to 0.70, moderate certainty) and duration of resuscitation of at least 15 minutes (0.12, 0.07 to 0.19, high certainty) were associated with reduced odds of survival.

CONCLUSION

Moderate to high certainty evidence was found for associations of pre-arrest and intra-arrest prognostic factors with survival after in-hospital cardiac arrest.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018104795.

The Danish in-hospital cardiac arrest registry (DANARREST)

Aim of database: The aim of DANARREST is to collect data on processes of care and outcomes for patients with in-hospital cardiac arrest in Denmark, and thereby facilitate and monitor quality and quality improvement initiatives. Study population: In-hospital cardiac arrest patients with a clinical indication for cardiopulmonary resuscitation in Denmark. Main variables: DANARREST includes a number of descriptive variables as well as seven quality of care indicators; four related to processes of care and three related to clinical outcomes. The four process measures are related to whether the cardiac arrest was witnessed, whether the cardiac arrest was ECG-monitored, the timing of cardiopulmonary resuscitation, and the timing of the first rhythm analysis. The three outcomes measures include return of spontaneous circulation, 30-day survival, and 1-year survival. Database status: DANARREST started in 2013, and the coverage has increased steadily since. As of 2017, 95% of relevant hospitals are reporting data with an estimated coverage rate of approximately 80%. Conclusion: DANARREST is a relatively new national registry of in-hospital cardiac arrests in Denmark, with a high coverage rate. The registry provides an opportunity to monitor and improve quality of care for patients with in-hospital cardiac arrest.

Real-time compression feedback for patients with in-hospital cardiac arrest: a multi-center randomized controlled clinical trial

Objective

To determine if real-time compression feedback using a non-automated hand-held device improves patient outcomes from in-hospital cardiac arrest (IHCA).

Methods

We conducted a prospective, randomized, controlled, parallel study (no crossover) of patients with IHCA in the mixed medical–surgical intensive care units (ICUs) of eight academic hospitals. Patients received either standard manual chest compressions or compressions performed with real-time feedback using the Cardio First Angel™ (CFA) device. The primary outcome was sustained return of spontaneous circulation (ROSC), and secondary outcomes were survival to ICU and hospital discharge.

Results

One thousand four hundred fifty-four subjects were randomized; 900 were included. Sustained ROSC was significantly improved in the CFA group (66.7% vs. 42.4%, P < 0.001), as was survival to ICU discharge (59.8% vs. 33.6%) and survival to hospital discharge (54% vs. 28.4%, P < 0.001). Outcomes were not affected by intra-group comparisons based on intubation status. ROSC, survival to ICU, and hospital discharge were noted to be improved in inter-group comparisons of non-intubated patients, but not intubated ones.

Conclusion

Use of the CFA compression feedback device improved event survival and survival to ICU and hospital discharge.

Trial registration

The study was registered with Clinicaltrials.gov (NCT02845011), registered retrospectively on July 21, 2016.

Is atrial fibrillation a risk factor for in-hospital cardiac arrest?: a Swedish retrospective cohort study

INTRODUCTION

Atrial fibrillation (AF) is associated with increased morbidity and mortality. Recent findings suggest that AF is also associated with out-of-hospital cardiac arrest. However, whether that association can be generalised to in-hospital cardiac arrests (IHCAs) is still unknown.

AIMS

To examine whether there is a stronger association with IHCA among hospitalised patients with AF compared with patients without AF.

MATERIALS AND METHODS

All adult patients admitted to the Karolinska University Hospital, Stockholm, Sweden during 2014-2015 were included. Data were drawn from their medical file and matched against the Swedish Registry for Cardiopulmonary Resuscitation. Patients who were documented as ever having the International Classification of Diseases, 10th revision code I48 prior to the current hospitalisation were categorised to the AF group and the remaining were categorised to the non-AF group. The primary outcome was occurrence of an IHCA.

RESULTS

In all, 102 416 patients were included. Among these, 10% had been diagnosed with AF and <1% (n=326) suffered from an IHCA, only 42 (13%) had a VF/VT. In a multivariable model adjusting for sex, age, CharlsonComorbidity Index score and whether the patients had been admitted electively or urgently, having AF was significantly associated with IHCA (OR 1.760; 95% CI 1.356 to 2.269; p<0.001).

CONCLUSIONS

Within this observational cohort study, patients with AF had a stronger association with IHCA than patients without AF. AF might be an independent risk factor for IHCA.

Adherence to advanced cardiovascular life support (ACLS) guidelines during in-hospital cardiac arrest is associated with improved outcomes

AIM OF THE STUDY

Identifying modifiable factors associated with survival following in-hospital cardiac arrest is crucial. The purpose of this study was to determine the extent to which adherence to the 2010 American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) guidelines in their entirety affects patient outcomes. In addition, we explored the role of code leader training level on patient outcomes.

METHODS

We conducted a retrospective review of records for cardiac arrests that occurred on hospital wards and were run by the hospital code team, at three tertiary care centres over 2 to 4 years. Deviations from the ACLS guidelines were quantified using a standardized checklist. Primary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge.

RESULTS

Of 160 resuscitation events, ROSC was achieved in 75 events (46.9%) and survival to hospital discharge in 20 patients (13.1%). On average, there were 2.3 deviations from ACLS guidelines during events that led to ROSC and 3.9 deviations during events that did not lead to ROSC (p < 0.0001). There were fewer deviations during events that led to survival to hospital discharge (2.1) compared to those where the patient did not survive to hospital discharge (3.1; p = 0.016). Code leader training level was not associated with patient outcomes. Multivariable logistic regression analysis confirmed an association between deviations from ACLS guidelines and ROSC, but not for survival to hospital discharge. The latter finding may reflect a very low survival rate.

CONCLUSION

We found that higher numbers of deviations from ACLS guidelines were associated with a lower likelihood of ROSC and survival to hospital discharge. These findings emphasize the importance of adherence to ACLS guidelines and the need for training healthcare personnel in resuscitation guidelines in order to improve outcomes for victims of in-hospital cardiac arrest.

Guideline-based intervention to reduce telemetry rates in a large tertiary centre

BACKGROUND

Inappropriate cardiac telemetry use is associated with reduced patient flow and increased healthcare costs.

AIM

To evaluate the outcomes of guideline-based application of cardiac telemetry.

METHODS

Phase I involved a prospective audit (March to August 2011) of telemetry use at a tertiary hospital. Data were collected on indication for telemetry and clinical outcomes. Phase II prospectively included patients more than 18 years under general medicine requiring ward-based telemetry. As phase II occurred at a time remotely from phase I, an audit similar to phase I (phase II - baseline) was completed prior to a 3-month intervention (May to August 2015). The intervention consisted of a daily telemetry ward round and an admission form based on the American Heart Association guidelines (class I, telemetry indicated; class II, telemetry maybe indicated; class III, telemetry not indicated). Patient demographics, telemetry data, and clinical outcomes were studied. Primary endpoint was the percentage reduction of class III indications, while secondary endpoint included telemetry duration.

RESULTS

In phase I (n = 200), 38% were admitted with a class III indication resulting in no change in clinical management. A total of 74 patients was included in phase II baseline (mean ± standard deviation (SD) age 73 years ± 14.9, 57% male), whilst 65 patients were included in the intervention (mean ± SD age 71 years ± 18.4, 35% male). Both groups had similar baseline characteristics. There was a reduction in class III admissions post-intervention from 38% to 11%, P < 0.001. Intervention was associated with a reduction in median telemetry duration (1.8 ± 1.8 vs 2.4 ± 2.5 days, P = 0.047); however, length of stay was similar in both groups (P > 0.05).

CONCLUSION

Guideline-based telemetry admissions and a regular telemetry ward round are associated with a reduction in inappropriate telemetry use.

Participatory design of probability-based decision support tools for in-hospital nurses

Objective

To describe nurses' preferences for the design of a probability-based clinical decision support (PB-CDS) tool for in-hospital clinical deterioration.

Methods

A convenience sample of bedside nurses, charge nurses, and rapid response nurses (n = 20) from adult and pediatric hospitals completed participatory design sessions with researchers in a simulation laboratory to elicit preferred design considerations for a PB-CDS tool. Following theme-based content analysis, we shared findings with user interface designers and created a low-fidelity prototype.

Results

Three major themes and several considerations for design elements of a PB-CDS tool surfaced from end users. Themes focused on "painting a picture" of the patient condition over time, promoting empowerment, and aligning probability information with what a nurse already believes about the patient. The most notable design element consideration included visualizing a temporal trend of the predicted probability of the outcome along with user-selected overlapping depictions of vital signs, laboratory values, and outcome-related treatments and interventions. Participants expressed that the prototype adequately operationalized requests from the design sessions.

Conclusions

Participatory design served as a valuable method in taking the first step toward developing PB-CDS tools for nurses. This information about preferred design elements of tools that support, rather than interrupt, nurses' cognitive workflows can benefit future studies in this field as well as nurses' practice.

Health Informatics via Machine Learning for the Clinical Management of Patients

OBJECTIVES

To review how health informatics systems based on machine learning methods have impacted the clinical management of patients, by affecting clinical practice.

METHODS

We reviewed literature from 2010-2015 from databases such as Pubmed, IEEE xplore, and INSPEC, in which methods based on machine learning are likely to be reported. We bring together a broad body of literature, aiming to identify those leading examples of health informatics that have advanced the methodology of machine learning. While individual methods may have further examples that might be added, we have chosen some of the most representative, informative exemplars in each case.

RESULTS

Our survey highlights that, while much research is taking place in this high-profile field, examples of those that affect the clinical management of patients are seldom found. We show that substantial progress is being made in terms of methodology, often by data scientists working in close collaboration with clinical groups.

CONCLUSIONS

Health informatics systems based on machine learning are in their infancy and the translation of such systems into clinical management has yet to be performed at scale.

External Validation of Two Classification and Regression Tree Models to Predict the Outcome of Inpatient Cardiopulmonary Resuscitation

OBJECTIVE

To prospectively validate a previously developed classification and regression tree (CART) model that predicts the likelihood of a good outcome among patients undergoing inpatient cardiopulmonary resuscitation.

DESIGN

Prospective validation of a clinical decision rule.

SETTING

Skåne University Hospital in Malmo, Sweden.

PATIENTS

All adult patients (N = 287) experiencing in-hospital cardiopulmonary arrest and undergoing cardiopulmonary resuscitation between 2007 and 2010.

INTERVENTIONS

Patients from Skåne University Hospital who underwent CPR (N = 287) were classified using the CART models to predict their likelihood of survival neurologically intact or with minimal deficits, based on a cerebral performance category score of 1. Discrimination and classification accuracy of the score in the Swedish population was compared to that in the original (derivation and internal validation) populations.

MEASUREMENTS AND MAIN RESULTS

For model 1, the area under the receiver-operating characteristic curve (AUROCC) was 0.77, compared with 0.76 and 0.73 in the original derivation and validation populations, respectively. Model 1 classified 71 (2.8%) of 287 patients as being at a very low risk of a good neurologic outcome compared with 157 (26.1%) of 287 patients predicted to be at an above average risk of a good neurologic outcome. Model 2 had a similar AUROCC as the original validation population of 0.71 but lower than the original derivation population. Model 2 performed similarly to Model 1 with regards to its ability to correctly classify patients as very low or higher than average likelihood of a good neurologic outcome.

CONCLUSION

Two CART models validated well in a different population, displaying similar discrimination and classification accuracy compared to the original population. Although additional validation in larger populations is desirable before widespread adoption, these results are very encouraging.

Life-threatening ventricular tachyarrhythmias in the cardiology department: Implications for appropriate prescription of telemetry monitoring

BACKGROUND

in-hospital life-threatening ventricular arrhythmias (LT-VA) may complicate the course of cardiovascular patients. We aimed to assess the incidence, circumstances, determinants, and outcome of in-hospital LT-VA in order to help clinicians in prescribing appropriate levels of monitoring.

METHODS

the study population consisted of all 10,741 consecutive patients (65 ± 15 years, 67.7% males) admitted to a cardiology department in 2009-2014. Terminally ill patients and those with primary arrhythmia diagnosis were excluded. The composite end-point included sudden arrhythmic death, ventricular fibrillation, unstable ventricular tachycardia and appropriate ICD shock unrelated to invasive interventions.

RESULTS

the incidence of LT-VA was 0.6%, with no differences regarding age, gender and primary diagnosis of coronary artery disease between patients with and without LT-VA. The incidence of LT-VA was significantly higher (1.2% versus 0.1%, p<0.001) among urgent compared with elective admissions and among patients with left ventricular ejection fraction (LV-EF) <45% (1.7% versus 0.2%, p<0.001). At multivariable analysis, urgent admission and LV-EF <45%, but not primary diagnosis of coronary artery disease, remained independent predictors of LT-VA. At the time of the event, 97.1% fulfilled either class I or class II indications for telemetry monitoring according to the American Heart Association guidelines. Survival to discharge with good neurological status was 70.6%.

CONCLUSIONS

acutely ill patients with heart failure and LV systolic dysfunction showed the highest rate of LT-VAs, regardless of the underlying cardiac disease (ischemic or non-ischemic). Current guidelines demonstrated high sensitivity in identifying patients at risk. These findings may favor proper utilization of telemetry monitoring resources.

Digitization of Electrocardiogram From Telemetry Prior to In-hospital Cardiac Arrest: A Pilot Study

BACKGROUND

Analyzing telemetry electrocardiogram (ECG) data over an extended period is often time-consuming because digital records are not widely available at hospitals. Investigating trends and patterns in the ECG data could lead to establishing predictors that would shorten response time to in-hospital cardiac arrest (I-HCA). This study was conducted to validate a novel method of digitizing paper ECG tracings from telemetry systems in order to facilitate the use of heart rate as a diagnostic feature prior to I-HCA.

METHODS

This multicenter study used telemetry to investigate full-disclosure ECG papers of 44 cardiovascular patients obtained within 1 hr of I-HCA with initial rhythms of pulseless electrical activity and asystole. Digital ECGs were available for seven of these patients. An algorithm to digitize the full-disclosure ECG papers was developed using the shortest path method. The heart rate was measured manually (averaging R-R intervals) for ECG papers and automatically for digitized and digital ECGs.

RESULTS

Significant correlations were found between manual and automated measurements of digitized ECGs (p < .001) and between digitized and digital ECGs (p < .001). Bland-Altman methods showed bias = .001 s, SD = .0276 s, lower and upper 95% limits of agreement for digitized and digital ECGs = .055 and -.053 s, and percentage error = 0.22%. Root mean square (rms), percentage rms difference, and signal to noise ratio values were in acceptable ranges.

CONCLUSION

The digitization method was validated. Digitized ECG provides an efficient and accurate way of measuring heart rate over an extended period of time.

Non-critical care telemetry and in-hospital cardiac arrest outcomes

BACKGROUND

Telemetry is increasingly used to monitor hospitalized patients with lower intensities of care, but its effect on in-hospital cardiac arrest (IHCA) outcomes in non-critical care patients is unknown.

HYPOTHESIS

Telemetry utilization in non-critical care patients does not affect IHCA outcomes.

METHODS

A retrospective cohort analysis of all patients in non-critical care beds that experienced a cardiac arrest in a university-affiliated teaching hospital during calendar years 2011 and 2012 was performed. Data were collected as part of AHA Get With the Guidelines protocol. The independent variable and exposure studied were whether patients were on telemetry or not. Telemetry was monitored from a central location. The primary endpoint was return of spontaneous circulation (ROSC) and the secondary end point was survival to discharge.

RESULTS

Of 123 IHCA patients, the mean age was 75±15 and 74 (61%) were male. 80 (65%) patients were on telemetry. Baseline demographics were similar except for age; patients on telemetry were younger with mean age of 70.3 vs. 76.8 in the non-telemetry group (p=0.024). 72 patients (60%) achieved ROSC and 46 (37%) achieved survival to discharge. By univariate analysis, there was no difference between patients that had been on telemetry vs. no telemetry in ROSC (OR=1.13, p=0.76) or survival to discharge (OR=1.18, p=0.67). Similar findings were obtained with multivariate analysis for ROSC (0.91, p=0.85) and survival to discharge (OR=0.92, p=0.87).

CONCLUSIONS

The use of cardiac telemetry in non-critical care beds, when monitored remotely in a central location, is not associated with improved IHCA outcomes.

Electrocardiogram characteristics prior to in-hospital cardiac arrest

Survival after in-hospital cardiac arrest (I-HCA) remains < 30 %. There is very limited literature exploring the electrocardiogram changes prior to I-HCA. The purpose of the study was to determine demographics and electrocardiographic predictors prior to I-HCA. A retrospective study was conducted among 39 cardiovascular subjects who had cardiopulmonary resuscitation from I-HCA with initial rhythms of pulseless electrical activity (PEA) and asystole. Demographics including medical history, ejection fraction, laboratory values, and medications were examined. Electrocardiogram (ECG) parameters from telemetry were studied to identify changes in heart rate, QRS duration and morphology, and time of occurrence and location of ST segment changes prior to I-HCA. Increased age was significantly associated with failure to survive to discharge (p < 0.05). Significant change was observed in heart rate including a downtrend of heart rate within 15 min prior to I-HCA (p < 0.05). There was a significant difference in heart rate and QRS duration during the last hour prior to I-HCA compared to the previous hours (p < 0.05). Inferior ECG leads showed the most significant changes in QRS morphology and ST segments prior to I-HCA (p < 0.05). Subjects with an initial rhythm of asystole demonstrated significantly greater ECG changes including QRS morphology and ST segment changes compared to the subjects with initial rhythms of PEA (p < 0.05). Diagnostic ECG trends can be identified prior to I-HCA due to PEA and asystole and can be further utilized for training a predictive machine learning model for I-HCA.

Evaluation of pre-arrest morbidity score and prognosis after resuscitation score and other clinical variables associated with in-hospital cardiac arrest in southern Sweden

OBJECTIVE

To evaluate pre-arrest morbidity score (PAM), prognosis after resuscitation score (PAR) and to identify additional clinical variables associated with survival after in-hospital cardiac arrest (IHCA) treated with cardiopulmonary resuscitation (CPR).

METHODS

A retrospective observational study involving all cases of IHCA at Skåne University Hospital Malmö 2007-2010.

RESULTS

Two-hundred-eighty-seven cases of IHCA were identified (61.3% male; mean age 70 years) of whom 20.2% survived until discharge. The odds ratio (95% confidence interval) for death prior to discharge was 6.49 (1.50-28.19) (p=0.013) for PAM>6 and 3.88 (1.95-7.73) (p<0.001) for PAR>4. At PAM- and PAR-scores >5, specificity exceeded 90%, while sensitivity was only 20-30%. The odds ratio for in-hospital mortality was 0.38 (0.20-0.72) (p=0.003) for patients with cardiac monitoring, 9.86 (5.08-19.12) (p<0.001) for non-shockable vs shockable rhythm, 0.32 (0.15-0.69) (p=0.004) for presence of ST-elevation myocardial infarction (STEMI), 0.27 (0.09-0.78) (p=0.016) for patients with independent Activities of Daily Life (ADL) and 13.86 (1.86-103.46) (p=0.010) for patients with malignancies. Heart rate (HR) on admission (per bpm) [1.024 (1.009-1.040) (p=0.002)] and sodium plasma concentration on admission (per mmoll(-1)) [0.92 (0.85-0.99) (p=0.023)] were significantly associated with in-hospital mortality.

CONCLUSION

PAM- and PAR-scores do not sufficiently discriminate between in-hospital death and survival after IHCA to be used as clinical tools guiding CPR decisions. We confirm that malignancy is associated with increased in-hospital mortality, and cardiac monitoring, shockable rhythm, STEMI and independent ADL, with decreased in-hospital mortality. Interestingly, our results suggest that HR and plasma sodium concentration upon admission may represent new tools for risk stratification.