In-hospital cardiac arrest after a rapid response team review: A matched case–control study

Rapid response team activation prior to in-hospital cardiac arrest: Areas for improvements based on a national cohort study

INTRODUCTION

Rapid response teams (RRTs) are designed to improve the "chain of prevention" of in-hospital cardiac arrest (IHCA). We studied the 30-day survival of patients reviewed by RRTs within 24 hours prior to IHCA, as compared to patients not reviewed by RRTs.

METHODS

A nationwide cohort study based on the Swedish Registry of Cardiopulmonary Resuscitation, between January 1st, 2014, and December 31st, 2021. An explorative, hypothesis-generating additional in-depth data collection from medical records was performed in a small subgroup of general ward patients reviewed by RRTs.

RESULTS

In all, 12,915 IHCA patients were included. RRT-reviewed patients (n = 2,058) had a lower unadjusted 30-day survival (25% vs 33%, p < 0.001), a propensity score based Odds ratio for 30-day survival of 0.92 (95% Confidence interval 0.90-0.94, p < 0.001) and were more likely to have a respiratory cause of IHCA (22% vs 15%, p < 0.001). In the subgroup (n = 82), respiratory distress was the most common RRT trigger, and 24% of the RRT reviews were delayed. Patient transfer to a higher level of care was associated with a higher 30-day survival rate (20% vs 2%, p < 0.001).

CONCLUSION

IHCA preceded by RRT review is associated with a lower 30-day survival rate and a greater likelihood of a respiratory cause of cardiac arrest. In the small explorative subgroup, respiratory distress was the most common RRT trigger and delayed RRT activation was frequent. Early detection of respiratory abnormalities and timely interventions may have a potential to improve outcomes in RRT-reviewed patients and prevent further progress into IHCA.

In-hospital cardiac arrest and preceding National Early Warning Score (NEWS): A retrospective case-control study

We aimed to describe and evaluate the National Early Warning Score (NEWS) in the 24 hours preceding an in-hospital cardiac arrest among general somatic ward patients.The 24 hours preceding the in-hospital cardiac arrest were divided into four timespans and analysed by a medical record review of 127:254 matched case-control patients. The median NEWS ranged from 3 (2-6) to 6 (3-9) points for cases vs 1 (0-3) to 1 (0-3) point for controls. The proportion of cases ranged from 23-45% at high risk vs 3-6% for controls. The NEWS high-risk category was associated with an increase of 3.17 (95% confidence interval (CI) 1.66-6.04) to 4.43 (95% CI 2.56-7.67) in odds of in-hospital cardiac arrest compared to the low-risk category.NEWS, with its intuitive and for healthcare staff easy to interpret risk classification, is suitable for discriminating deteriorating patients with major deviating vital signs scoring high risk on NEWS.

Surviving cardiac arrest: What happens after admission to the intensive care unit?

INTRODUCTION

Patients successfully resuscitated from cardiac arrest (CA) are admitted to the intensive care unit (ICU) for post-resuscitation care. These patients' prognosis remains dismal, with only a minority surviving to hospital discharge. Understanding the clinical factors involved in the management of these patients is essential to improve their prognosis.

OBJECTIVES

To characterize the population admitted after successful reanimation from CA, and to analyze the factors associated with their outcomes.

METHODS

We performed a retrospective descriptive study of patients admitted to an ICU after CA over a five-year period from January 2014 to December 2018. Demographic factors, CA characteristics, early management, mortality and neurologic outcomes were analyzed.

RESULTS

A total of 187 patients, median age 67 years, were admitted after CA, of whom 39% suffered out-of-hospital CA; 87% had an initial non-shockable rhythm and the most frequent presumed cause was cardiac (31%). In-hospital mortality was 63%. Significant neurologic dysfunction (cerebral performance category 3 or 4) was seen in 31% of survivors at hospital discharge. Non-immediate initiation of basic life support (BLS), higher Simplified Acute Physiology Score II score and longer relative duration of vasopressor support were independent predictors of in-hospital mortality, while shockable rhythms were associated with improved survival. Higher Glasgow coma scale at ICU discharge and shorter length of ICU stay were predictors of better neurologic outcome.

CONCLUSION

This study highlights the positive prognostic impact of shockable rhythms, and confirms the importance of immediate initiation of BLS and prompt defibrillation, supporting the need for better training both outside and inside hospitals.

Surviving cardiac arrest: What happens after admission to the intensive care unit?

INTRODUCTION

Patients successfully resuscitated from cardiac arrest (CA) are admitted to the intensive care unit (ICU) for post-resuscitation care. These patients' prognosis remains dismal, with only a minority surviving to hospital discharge. Understanding the clinical factors involved in the management of these patients is essential to improve their prognosis.

OBJECTIVES

To characterize the population admitted after successful reanimation from CA, and to analyze the factors associated with their outcomes.

METHODS

We performed a retrospective descriptive study of patients admitted to an ICU after CA over a five-year period from January 2014 to December 2018. Demographic factors, CA characteristics, early management, mortality and neurologic outcomes were analyzed.

RESULTS

A total of 187 patients, median age 67 years, were admitted after CA, of whom 39% suffered out-of-hospital CA; 87% had an initial non-shockable rhythm and the most frequent presumed cause was cardiac (31%). In-hospital mortality was 63%. Significant neurologic dysfunction (cerebral performance category 3 or 4) was seen in 31% of survivors at hospital discharge. Non-immediate initiation of basic life support (BLS), higher Simplified Acute Physiology Score II score and longer relative duration of vasopressor support were independent predictors of in-hospital mortality, while shockable rhythms were associated with improved survival. Higher Glasgow coma scale at ICU discharge and shorter length of ICU stay were predictors of better neurologic outcome.

CONCLUSION

This study highlights the positive prognostic impact of shockable rhythms, and confirms the importance of immediate initiation of BLS and prompt defibrillation, supporting the need for better training both outside and inside hospitals.

European Resuscitation Council Guidelines 2021: Systems saving lives

The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.

The illness severity of patients reviewed by the medical emergency team: A scoping review

BACKGROUND

Medical emergency teams (METs) are internationally used to manage hospitalised deteriorating patients. Although triggers for MET review and hospital outcomes have previously been widely reported, the illness severity at the point of MET review has not been reported. As such, levels of clinical acuity and patient dependency representing the risk of exposure to short-term adverse clinical outcomes remain largely unknown.

OBJECTIVE

This scoping review sought to understand the illness severity of MET review recipients in terms of acuity and dependency.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The published and grey literature since 2009 was searched to identify relevant articles reporting illness severity scores associated with hospitalised adult inpatients reviewed by a MET. After applying the inclusion and exclusion criteria, 17 articles (16 quantitative studies, one mixed-methods study) were reviewed, summarised, collated, and reported.

RESULTS

A total of 17 studies reported clinical acuity metrics for patients reviewed by a MET. No studies described an integrated risk score encompassing acuity, patient dependency, or wider parameters that might be associated with increased patient risk or the need for intervention. Multi-MET review, the use of specialist interventions, and delayed/transfer to the intensive care unit were associated with a greater risk of clinical deterioration, higher clinical acuity score, and predicted mortality risk. A single dependency metric was not reported although organisational levels of care, the duration of MET review, MET interventions, chronic illness, and frailty were inferred proxy measures.

CONCLUSION

Of the 17 studies reviewed, no single study provided an integrated assessment of illness severity from which to stratify risk or support patient management processes. Patients reviewed by a MET have variable and rapidly changing health needs that make them particularly vulnerable. The lack of high-quality data reporting acuity and dependency limits our understanding of true clinical risk and subsequent opportunities for pathway development.

The pre-Medical Emergency Team response: Nurses' decision-making escalating deterioration to treating teams using urgent review criteria

AIM

To describe nurses' decision-making, experiences and perceptions of escalating deteriorating patients to the treating medical team using urgent clinical review criteria.

DESIGN

A qualitative design comprising individual in-depth interviews with nurses from a major Australian metropolitan tertiary teaching hospital.

METHOD

A purposive sample of 30 Registered Nurses from nine surgical and medical wards were interviewed in April 2018 using semi-structured interviews. An inductive thematic analysis was conducted.

RESULTS

Identified themes included: detecting the deterioration; countering the problem; getting a response; and challenges faced in the process of escalation. Nurses reported an important awareness, sense of responsibility, and critical thinking to ensure the safe management and escalation of deteriorating patients. However, barriers to escalation necessitated individual workarounds and organizational structures to mitigate patient risk.

CONCLUSION

This study supports the importance of communication between clinical teams and recognizes that it is crucial to enable a fail-safe experience for patients and families. Recognition of disciplinary contributions to patients' goals of care is required to better understand and address the prevalence of deteriorating patients. Our study is among the first to explore the actual experience of nurses who articulate balancing uncertainty and managing complex team dynamics on wards for patients experiencing deteriorating health status. The information may assist in determining team training strategies and structures to facilitate patient management during deterioration.

IMPACT

This is among the first study to investigate barriers influencing decision-making of RNs prior to escalation using qualitative methods. This study provides a foundation to inform and develop policies and strategies aimed at ensuring escalation occurs for deteriorating patients.

Predictors of in-hospital cardiac arrest within 24 h after emergency department triage: A case-control study in urban Thailand

OBJECTIVE

This study describes the predictors of in-hospital cardiac arrest (IHCA) within 24 h of ED triage and evaluates their ability to predict patients at risk of IHCA.

METHODS

A case-control study was conducted in the ED. 'Cases' are herein defined as hospitalised patients who experienced IHCA within 24 h after ED triage. The exclusion criteria were those younger than 16 years old, cases of traumatic arrest, or had do-not-resuscitate orders. The controls were adults, non-traumatic cases, who did not experience IHCA within 24 h of ED triage. A multivariable regression model was used to identify significant predictors of IHCA. The ability to discriminate was quantified by utilising an area under receiver operating characteristic (AuROC) curve.

RESULTS

Two hundred and fifty IHCAs were compared with 1000 controls. Five predictors emerged that were: higher National Early Warning Score (NEWS) at triage, equal or increase of NEWS after ED management, coronary artery disease as a comorbid disease, the use of a vasoactive agent, and initial serum bicarbonate level lower than 23.5 mmoL/L, independently associated with IHCA. The AuROC of the final model from all predictors was 0.91 (95% CI 0.89-0.93) higher than NEWS alone model (AuROC at 0.78, 95% CI 0.74-0.81).

CONCLUSIONS

We conclude that a combination of NEWS and four independent predictors identify patients at risk of IHCA more effectively than NEWS alone.

Evaluation of the efficacy of the National Early Warning Score in predicting in-hospital mortality via the risk stratification

PURPOSE

To investigate the efficacy of the National Early Warning Score (NEWS) in predicting in-hospital mortality.

MATERIALS AND METHODS

This was a retrospective observational study and the electronic medical records of the patients were reviewed based on NEWS at the time of admission.

RESULTS

The performance of NEWS was effective in predicting hospital mortality (area under the curve: 0.765; 95% confidence interval: 0.659-0.846). Based on the Kaplan Meier survival curves, the survival time of patients who are at high risk according to NEWS was significantly shorter than that of patients who are at low risk (p < 0.001). Results of the multivariate Cox proportional hazards regression analysis showed that the hazard ratios of patients who are at medium and high risk based on NEWS were 2.6 and 4.7, respectively (p < 0.001). In addition, our study showed that the combination model that used other factors, such as age and diagnosis, was more effective than NEWS alone in predicting hospital mortality (NEWS: 0.765; combination model: 0.861; p < 0.005).

CONCLUSIONS

NEWS is a simple and useful bedside tool for predicting in-hospital mortality. In addition, the rapid response team must consider other clinical factors as well as screening tools to improve clinical outcomes.