Characteristics and outcome among patients suffering in-hospital cardiac arrest in monitored and non-monitored areas

Compliance with cardiopulmonary resuscitation guidelines in witnessed in-hospital cardiac arrest events and patient outcome on monitored versus non-monitored wards

BACKGROUND

Adherence to cardiopulmonary resuscitation (CPR) guidelines in treatment of in-hospital cardiac arrest (IHCA) have been associated with favourable patient outcome. The aim of this study was to evaluate if compliance with initial CPR guidelines and patient outcome of witnessed IHCA events were associated with the place of arrest defined as monitored versus non-monitored ward.

METHODS

A total of 956 witnessed IHCA events in adult patients at six hospitals during 2018 to 2019, were extracted from the Swedish Registry of Cardiopulmonary Resuscitation. Initial CPR guidelines were: ≤1 min from collapse to alert of the rapid response team, ≤1 min from collapse to start of CPR, ≤3 min from collapse to defibrillation of shockable rhythm.

RESULTS

The odds of compliance with guidelines was higher on monitored wards vs non-monitored wards, even after adjustment for factors that could affect staffing and resources. The place of arrest was not a significant factor for sustained return of spontaneous circulation, survival at 30 days, or neurological status at discharge, when adjusting for clinically relevant confounders. Compliance with initial CPR guidelines remained a significant factor for survival to 30 days and favourable neurological outcome at discharge regardless of other confounders.

CONCLUSION

Compliance with initial CPR guidelines was higher in witnessed IHCA events on monitored wards than on non-monitored wards, which indicates that healthcare professionals in monitored wards are quicker to recognize a cardiac arrest and initiate treatment. When initial CPR guidelines are followed, the place of arrest does not influence patient outcome.

The epidemiology and outcomes of adult in-hospital cardiac arrest in a high-income developing country

Aim

Methods

Results

Conclusion

Impact of holiday periods on survival following an in-hospital cardiac arrest

Introduction

Higher rates of mortality following an in-hospital cardiac arrest (IHCA) has been shown during nights and weekends, changes in staff density and composition has been suggested as a possible explanation. Changes in hospital staffing patterns are also common during holiday periods.

Aim

To investigate whether holiday periods are associated with decreased survival following an IHCA.

Material and methods

All patients ≥18 years who experienced an IHCA at Karolinska University Hospital between 2006 and 2019 were included. Patients were identified via and data was collected from the Swedish Registry for Cardiopulmonary Resuscitation. Holiday was defined as two periods, a seven-week summer period and an approximately two-week Christmas period. The primary outcome was return of spontaneous circulation (ROSC), secondary survival to hospital discharge. Logistic regression was performed to calculate odds ratio (OR) with 95% confidence intervals (CI), adjustment was done for known confounders.

Results

Out of 1936 registered cases, 264 (14%) occurred during holiday periods. Patient and event characteristics were similar on holidays compared to non-holidays. Both ratio for ROSC (45% and 55%, respectively) and survival (25% and 32% respectively) was poorer during holiday periods Adjusted OR for ROSC and survival was poorer during holiday periods compared non-holiday periods (OR 0.69 [95% CI, 0.53-0.92] and OR 0.69 [95% CI, 0.49-0.96], respectively).

Conclusion

Outcomes after IHCA was poorer during holiday periods compared to non-holiday periods even if patient and event characteristics was similar. Further research is needed to better understand to what degree staffing patterns and other factors contribute to the observed difference.

Follow the protocol and kickstart the heart-Intensive care nurses' reflections on being part of rescue situations in interdisciplinary teams

Aim

To describe intensive care nurses' reflections on being part of interdisciplinary emergency teams involved in in‐hospital cardiopulmonary resuscitation.

Design

A qualitative descriptive design. Methods: Eighteen intensive care nurses from two regions and three hospitals in Sweden were interviewed. The data were analysed with General Inductive Analysis.

Results

The work for intensive care nurses in the emergency team was reflected in three phases: prevention, intervention and mitigation—referred as before, during and after the CPR situation.

Conclusions

The findings describe the complexity of being an intensive care nurse in an interdisciplinary emergency team, which entails managing advanced care with limited and unknown resources in a non‐familiar environment. The present findings have important clinical implications concerning the value of having debriefing sessions to reflect on and to talk about obstacles to and prerequisites for performing successful resuscitation.

One of the Team Is Down! An On-Duty Paramedic in Prolonged Cardiac Arrest

A 29-year-old male paramedic on duty in a hospital-based emergency medical service system presented to the emergency room with complaints of chronic midback pain. In 2019, when the patient was on duty and complained of back pain for over 3 days, his supervisor instructed him to go to the emergency room. The patient collapsed and went into cardiac arrest; he received a total of 16 doses of 1 mg epinephrine (10 mL of a 1:10,000 solution), 2 doses of amiodarone, 1 dose of sodium bicarbonate, and an infusion of beta blocker agents, which were administered throughout the resuscitation that lasted for 63 minutes. The patient was discharged 27 days later with a patient cerebral performance category score of 1 and no neurologic deficit. Prolongation of resuscitation attempts can result in good outcomes for selected patients.

Assessing the effect of arrival time of physician and cardiopulmonary resuscitation (CPR) team on the outcome of CPR

Introduction

Negligence of proper time and poor performance of resuscitation team can lead to more mortality and negative consequences of cardiac arrest, as well as less survival. This study was conducted with objective of determining the arrival time of physician and resuscitation team to survive the victims of cardiopulmonary arrest.

Materials and methods

In this prospective and descriptive-analytic study, the resuscitation performance and the arrival time of resuscitation team in 143 inpatients who had been diagnosed with witnessed cardiopulmonary arrest were examined using a researcher-made checklist. Data analysis was performed using parametric and non-parametric statistical tests and SPSS.

Results

Initial survival rate was 26.6%. In general, the mean time of physician’s presence after the code announcement in minutes and seconds was 02:31 ± 01:22. It was also 02:24 ± 01:15 in successful cases and 02:34 ± 01:25 in unsuccessful cases. Independent t-test did not show a significant difference between the physician’s presence time and the rate of initial successful resuscitation (p = 0.504). The time of first shock after observing ventricular fibrillation/tachycardia (in minutes and seconds) was 01:30 ± 00:47. According to independent t-test, the aforementioned time was less than the mean time (02:31 ± 01:22) of physician’s presence (p < 0.001).

Conclusions

In this study, the initial survival rate in comparison to other regions in the country was almost more favorable and it was similar to global norms. In this study, the starting time of resuscitation was within the acceptable range. There was no relationship between the presence of physician and the initial survival rate of patients, as well as the use of defibrillator (by physician compared to other team members) and intubation with the initial survival rate. This could indicate the adequate performance of resuscitation team in the absence of physician on the condition of having sufficient knowledge and skill.

Cardiac arrest after pulmonary aspiration in hospitalised patients: a national observational study

OBJECTIVE

To study characteristics and outcomes among patients with in-hospital cardiac arrest (IHCA) due to pulmonary aspiration.

DESIGN

A retrospective observational study based on data from the Swedish Registry of Cardiopulmonary Resuscitation (SRCR).

SETTING

The SRCR is a nationwide quality registry that covers 96% of all Swedish hospitals. Participating hospitals vary in size from secondary hospitals to university hospitals.

PARTICIPANTS

The study included patients registered in the SRCR in the period 2008 to 2017. We compared patients with IHCA caused by pulmonary aspiration (n=127), to those with IHCA caused by respiratory failure of other causes (n=2197).

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was 30-day survival. Secondary outcome was sustained return of spontaneous circulation (ROSC) defined as ROSC at the scene and admitted alive to the intensive care unit.

RESULTS

In the aspiration group 80% of IHCA occurred on general wards, as compared with 63.6% in the respiratory failure group (p<0.001). Patients in the aspiration group were less likely to be monitored at the time of the arrest (18.5% vs 38%, p<0.001) and had a significantly lower rate of sustained ROSC (36.5% vs 51.6%, p=0.001). The unadjusted 30-day survival rate compared with the respiratory failure group was 7.9% versus 18.0%, p=0.024. In a propensity score analysis (including variables; year, age, gender, location of arrest, initial heart rhythm, ECG monitoring, witnessed collapse and a previous medical history of; cancer, myocardial infarction or heart failure) the OR for 30-day survival was 0.46 (95% CI 0.19 to 0.94).

CONCLUSIONS

In-hospital cardiac arrest preceded by pulmonary aspiration occurred more often on general wards among unmonitored patients. These patients had a lower 30-day survival rate compared with IHCA caused by respiratory failure of other causes.

Reducing Telemetry Use Is Safe: A Retrospective Analysis of Rapid Response Team and Code Events After a Successful Intervention to Reduce Telemetry Use

Interventions guiding appropriate telemetry utilization have successfully reduced use at many hospitals, but few studies have examined their possible adverse outcomes. The authors conducted a successful intervention to reduce telemetry use in 2013 on a hospitalist service using educational modules, routine review, and financial incentives. The association of reduced telemetry use with the incidence of rapid response team (RRT) and code activations was assessed in a retrospective cohort study of 210 patients who experienced a total of 233 RRT and code events on the inpatient internal medicine services from January 2012 through March 2015 at a tertiary care center. The incidence of adverse events for the hospitalist service was not significantly different during the intervention and postintervention period as compared to the preintervention period. Reducing inappropriate telemetry use was not associated with an increase in the incidence rates of RRT and code events.

In-hospital cardiac arrest resuscitation performed by the hospital emergency team: A 6-year retrospective register analysis at Danderyd University Hospital, Sweden

Background: Cardiac arrest requires rapid and effective handling. Huge efforts have been implemented to improve resuscitation of sudden cardiac arrest patients. Guidelines around the various parts of effective management, the chain of survival, are available. The aim of the present retrospective study was to study sudden in-hospital cardiac arrest (IHCA) and the outcomes of emergence team resuscitation in a university hospital in Sweden. Methods: The Swedish Cardiopulmonary Resuscitation Registry was used to access all reported cases of IHCA at Danderyd Hospital from 2012 through 2017. Return of spontaneous circulation (ROSC), discharge alive, 30-day mortality and Cerebral Performance Scales score (CPC) were analysed. Results: 574 patients with cardiac arrests were included in the study: 307 patients (54%) had ROSC; 195 patients (34%) were alive to be discharged from hospital; and 191 patients (33%) were still alive at day-30 after cardiac arrest. Witnessed cardiac arrests, VT/VF as initial rhythm and experiencing cardiac arrest in high monitored wards were factors associated with success. However, 53% of patients' alive at day-30 had a none-shockable rhythm, 16% showed initially a pulseless electrical activity and 37% asystole. CPC score was available for 188 out of the 195 patients that were alive to be discharged: 96.5% of patients where data was available had a favourable neurological outcome, a CPC-score of 1 or 2 at discharge, and only 6 of these patients had a CPC-score of 3 or higher (3%). Conclusions: One third of patients with sudden IHCA were discharged from hospital and alive at day-30, a clear majority without cognitive deficit related to the cardiac arrest. High monitored care, witnessed cardiac arrest and shockable rhythm were factors associated with high success; however, more than half of surviving patients had initially a none-shockable rhythm.

Survival and neurological outcome in the elderly after in-hospital cardiac arrest

BACKGROUND

There have been few studies of the outcome in elderly patients who have suffered in-hospital cardiac arrest (IHCA) and the association between cardiac arrest characteristics and survival.

AIM

The aim of this large observational study was to investigate the survival and neurological outcome in the elderly after IHCA, and to identify which factors were associated with survival.

METHODS

We investigated elderly IHCA patients (≥70years of age) who were registered in the Swedish Cardiopulmonary Resuscitation Registry 2007-2015. For descriptive purposes, the patients were grouped according to age (70-79, 80-89, and ≥90years). Predictors of 30-day survival were identified using multivariable analysis.

RESULTS

Altogether, 11,396 patients were included in the study. Thirty-day survival was 28% for patients aged 70-79 years, 20% for patients aged 80-89 years, and 14% for patients aged ≥90years. Factors associated with higher survival were: patients with an initially shockable rhythm, IHCA at an ECG-monitored location, IHCA was witnessed, IHCA during daytime (8 a.m.-8 p.m.), and an etiology of arrhythmia. A lower survival was associated with a history of heart failure, respiratory insufficiency, renal dysfunction and with an etiology of acute pulmonary oedema. Patients over 90 years of age with VF/VT as initial rhythm had a 41% survival rate. We found a trend indicating a less aggressive care with increasing age during cardiac arrest (fewer intubations, and less use of adrenalin and anti-arrhythmic drugs) but there was no association between age and delay in starting cardiopulmonary resuscitation (CPR). In survivors, there was no significant association between age and a favourable neurological outcome (CPC score: 1-2) (92%, 93%, and 88% in the three age groups, respectively).

CONCLUSIONS

Increasing age among the elderly is associated with a lower 30-day survival after IHCA. Less aggressive treatment and a worse risk profile might contribute to these findings. Relatively high survival rates among certain subgroups suggest that discussions about advanced directives should be individualized. Most survivors have good neurological outcome, even patients over 90 years of age.

Failure to activate the in-hospital emergency team: causes and outcomes

Objective

To determine the incidence of afferent limb failure of the in-hospital Medical Emergency Team, characterizing it and comparing the mortality between the population experiencing afferent limb failure and the population not experiencing afferent limb failure.

Methods

A total of 478 activations of the Medical Emergency Team of Hospital Pedro Hispano occurred from January 2013 to July 2015. A sample of 285 activations was obtained after excluding incomplete records and activations for patients with less than 6 hours of hospitalization. The sample was divided into two groups: the group experiencing afferent limb failure and the group not experiencing afferent limb failure of the Medical Emergency Team. Both populations were characterized and compared. Statistical significance was set at p ≤ 0.05.

Result

Afferent limb failure was observed in 22.1% of activations. The causal analysis revealed significant differences in Medical Emergency Team activation criteria (p = 0.003) in the group experiencing afferent limb failure, with higher rates of Medical Emergency Team activation for cardiac arrest and cardiovascular dysfunction. Regarding patient outcomes, the group experiencing afferent limb failure had higher immediate mortality rates and higher mortality rates at hospital discharge, with no significant differences. No significant differences were found for the other parameters.

Conclusion

The incidence of cardiac arrest and the mortality rate were higher in patients experiencing failure of the afferent limb of the Medical Emergency Team. This study highlights the need for health units to invest in the training of all healthcare professionals regarding the Medical Emergency Team activation criteria and emergency medical response system operations.

Cardiopulmonary resuscitation of adults with in-hospital cardiac arrest using the Utstein style

Objective

The objective of this study was to analyze the clinical profile of patients with in-hospital cardiac arrest using the Utstein style.

Methods

This study is an observational, prospective, longitudinal study of patients with cardiac arrest treated in intensive care units over a period of 1 year.

Results

The study included 89 patients who underwent cardiopulmonary resuscitation maneuvers. The cohort was 51.6% male with a mean age 59.0 years. The episodes occurred during the daytime in 64.6% of cases. Asystole/bradyarrhythmia was the most frequent initial rhythm (42.7%). Most patients who exhibited a spontaneous return of circulation experienced recurrent cardiac arrest, especially within the first 24 hours (61.4%). The mean time elapsed between hospital admission and the occurrence of cardiac arrest was 10.3 days, the mean time between cardiac arrest and cardiopulmonary resuscitation was 0.68 min, the mean time between cardiac arrest and defibrillation was 7.1 min, and the mean duration of cardiopulmonary resuscitation was 16.3 min. Associations between gender and the duration of cardiopulmonary resuscitation (19.2 min in women versus 13.5 min in men, p = 0.02), the duration of cardiopulmonary resuscitation and the return of spontaneous circulation (10.8 min versus 30.7 min, p < 0.001) and heart disease and age (60.6 years versus 53.6, p < 0.001) were identified. The immediate survival rates after cardiac arrest, until hospital discharge and 6 months after discharge were 71%, 9% and 6%, respectively.

Conclusions

The main initial rhythm detected was asystole/bradyarrhythmia; the interval between cardiac arrest and cardiopulmonary resuscitation was short, but defibrillation was delayed. Women received cardiopulmonary resuscitation for longer periods than men. The in-hospital survival rate was low.

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.

Aetiology of in-hospital cardiac arrest on general wards

AIM

Aetiology of in-hospital cardiac arrests (IHCAs) on general wards has not been studied. We aimed to determine the underlying causes for IHCAs by the means of autopsy records and clinical judgement of the treating consultants. Furthermore, we investigated whether aetiology and preceding vital dysfunctions are associated with long-term survival.

DESIGN AND SETTING

Prospective observational study between 2009-2011 including 279 adult IHCA patients attended by medical emergency team in a Finnish university hospital's general wards.

RESULTS

The median age of the patients was 72 (64, 80) years, 185 (66%) were male, 178 (64%) of events were monitored/witnessed, first rhythm was shockable in 42 (15%) cases and 53 (19%) patients survived six months. Aetiology was determined as cardiac in 141 events, 73 of which were due to acute myocardial infarction. There were 138 non-cardiac IHCAs; most common causes were pneumonia (39) and exsanguination (16). No statistical difference was observed in the incidence of objective vital dysfunctions preceding the event between the cardiac and non-cardiac groups (40% vs. 44%, p=0.448). Subjective antecedents were more common in the cardiac cohort (47% vs. 32%, p=0.022), chest pain being an example (11% vs. 0.7%, p<0.001). Reviewing all 279 IHCAs, only shockable primary rhythm, monitored/witnessed event and low comorbidity score were independently associated with 180-day survival.

CONCLUSIONS

Cardiac aetiology underlies half of the IHCAs on general wards. Both objective and subjective antecedents are common. However, neither the cardiac aetiology nor the absence of preceding deterioration of vital signs were factors independently associated with a favourable outcome.

The Impact of Monitoring on the Initiation of Cardiopulmonary Resuscitation in Children: Friend or Foe?

BACKGROUND

The immediate initiation and high quality of basic life support (BLS) are pivotal to improving patient outcome after cardiac arrest. Although cardiorespiratory monitoring could shorten the time to recognize the onset of cardiac arrest, little is known about how monitoring and the misinterpretation of monitor readings could impair the initiation of BLS. In this study, we assessed the speed of initiation and quality of BLS in simulated monitored and nonmonitored pediatric cardiac arrest.

METHODS

Sixty residents frequently involved in the care of critically ill children were randomly assigned to either the intervention (monitoring) group or the control (nonmonitoring) group. Participants of both groups performed BLS in 1 of 2 clinically identical, unwitnessed simulated cardiac arrest scenarios. Although in 1 scenario cardiorespiratory monitoring (i.e., electrocardiogram) was attached, the other scenario reflected a nonmonitored cardiac arrest. Time to first chest compression was chosen as the primary outcome variable. Adherence to resuscitation guidelines and subjective performance ratings were secondary outcome variables.

RESULTS

Participants in the monitoring group initiated chest compressions significantly later than those in the nonmonitoring group (91 ± 36 vs 71 ± 26 seconds, hazard ratio, 0.26; 95% confidence interval, 0.14-0.49, P < 0.001). Six members of the monitoring group did not start chest compression within 5 minutes. Furthermore, adherence to the guidelines was better in the nonmonitoring group. Participants who were previously involved in BLS training did not show better performance.

CONCLUSIONS

The presence of cardiorespiratory monitoring significantly delayed or even prevented the initiation of chest compressions and impaired the quality of BLS in simulated pediatric cardiac arrest. Based on these data, specific training should be conducted for exposed personnel.

Diurnal variation in the performance of rapid response systems: the role of critical care services-a review article

The type of medical review before an adverse event influences patient outcome. Delays in the up-transfer of patients requiring intensive care are associated with higher mortality rates. Timely detection and response to a deteriorating patient constitute an important function of the rapid response system (RRS). The activation of the RRS for at-risk patients constitutes the system’s afferent limb. Afferent limb failure (ALF), an important performance measure of rapid response systems, constitutes a failure to activate a rapid response team (RRT) despite criteria for calling an RRT.

There are diurnal variations in hospital staffing levels, the performance of rapid response systems and patient outcomes. Fewer ward-based nursing staff at night may contribute to ALF. The diurnal variability in RRS activity is greater in unmonitored units than it is in monitored units for events that should result in a call for an RRT. RRT events include a significant abnormality in either the pulse rate, blood pressure, conscious state or respiratory rate. There is also diurnal variation in RRT summoning rates, with most activations occurring during the day. The reasons for this variation are mostly speculative, but the failure of the afferent limb of RRT activation, particularly at night, may be a factor.

The term “circadian variation/rhythm” applies to physiological variations over a 24-h cycle. In contrast, diurnal variation applies more accurately to extrinsic systems. Circadian rhythm has been demonstrated in a multitude of bodily functions and disease states.

For example, there is an association between disrupted circadian rhythms and abnormal vital parameters such as anomalous blood pressure, irregular pulse rate, aberrant endothelial function, myocardial infarction, stroke, sleep-disordered breathing and its long-term consequences of hypertension, heart failure and cognitive impairment. Therefore, diurnal variation in patient outcomes may be extrinsic, and more easily modifiable, or related to the circadian variation inherent in human physiology. Importantly, diurnal variations in the implementation and performance of the RRS, as gauged by ALF, the RRT response to clinical deterioration and any variations in quality and quantity of patient monitoring have not been fully explored across a diverse group of hospitals.

Incidence and outcome of adult in-hospital cardiac arrest in Beijing, China

OBJECTIVE

To assess the incidence and outcome of in-hospital cardiac arrests (IHCAs) in Beijing, China.

METHODS

The incidence and outcome of IHCAs over a 12-month period were evaluated in this prospective study. Between January 1 and December 31, 2014, 12 Beijing hospitals prospectively participated in this study for calculation of the incidence of IHCA. Data were collected according to the Utstein style for all cases of attempted resuscitation for IHCA that occurred in the participating hospitals. Surviving patients were followed for 1 month.

RESULTS

The total number of admissions across the 12 hospitals during this 1-year period was 582,242; the IHCA incidence was 17.5 per 1000 admissions. Of the 10,198 IHCAs recorded, cardiopulmonary resuscitation (CPR) was initiated in 26.6%. Among CPR recipients, 1292 (47.6%) had a presumed cardiac aetiology and 1255 occurred in the Emergency Department. With regards to initial rhythm, 1340 had asystole and 423 had shockable rhythms. Of those receiving CPR, 1451 (53.5%) patients received it in less than 1min. Restoration of spontaneous circulation was achieved in 962 (35.5%) patients; 247 (9.1%) patients were discharged alive and 174 (6.4%) patients had good neurological outcomes. At 1 month after discharge, 236 patients remained alive. On multivariate regression analysis, factors associated with survival included female sex, age <60 years, and ventricular fibrillation/ventricular tachycardia as the initial rhythm.

CONCLUSION

The incidence of IHCA in Beijing hospitals is high and the survival is poor compared to other industrialized countries.

Clinical Characteristics and Mortality of Life-Threatening Events Requiring Cardiopulmonary Resuscitation in Gastrointestinal Endoscopy Units

Little is known about life-threatening events during gastrointestinal endoscopy (GIE). This study aimed to evaluate the clinical characteristics of emergency conditions requiring cardiopulmonary resuscitation (CPR) in GIE units and to assess the risk factors for mortality in these cases.We retrospectively collected life-threatening cases that occurred in the GIE units of 6 tertiary hospitals from January 2012 to June 2014. Cases were defined as alert calls for resuscitation teams in emergency situations of respiratory failure or cardiac arrest. Demographic data, clinical features, and probable causes were assessed. Factors associated with mortality were elucidated using logistic regression analysis.Among 263,426 endoscopies, 40 cases of CPR (0.015%) occurred during the period (male 67.5%, median age 62 yr). Gastrointestinal bleeding (GIB), such as hematemesis or melena, was the most common indication for endoscopy (55%). The types of clinical situations encountered were as follows: respiratory insufficiency (47.5%), decreased blood pressure (25%), and cardiac arrhythmia (25%). Although most of these conditions were detected during endoscopy (67.5%), one-third of cases (32.5%) were found before or after procedures. The most frequent probable cause of cases was aggravation of underlying diseases (57.5%), such as uncontrolled bleeding or exacerbation of lung disease. Despite efforts to resuscitate, 18 patients (45%) died. GIB was the single independent risk factor for mortality (odds ratio 28.45, 95% confidence interval 1.55-523.33, P = 0.024).Life-threatening situations requiring CPR can occur during endoscopy, even before or after the procedure. Greater attention should be paid while endoscopy is performed for GIB.

Modified Early Warning Score Changes Prior to Cardiac Arrest in General Wards

Purpose

The frequency, extent, time frame, and implications of changes to the modified early warning score (MEWS) in the 24 hours prior to cardiac arrest are not known. Our aim was to determine the prevalence and trends of the MEWS prior to in-hospital cardiac arrest (IHCA) on a ward, and to evaluate the association between changes in the MEWS and in-hospital mortality.

Methods

A total of 501 consecutive adult IHCA patients who were monitored and resuscitated by a medical emergency team on the ward were enrolled in the study between March 2009 and February 2013. The MEWS was calculated at 24 hours (MEWS₂₄), 16 hours (MEWS₁₆), and 8 hours (MEWS₈) prior to cardiac arrest.

Results

Out of 380 patients, 268 (70.5%) had a return of spontaneous circulation. The survival rate to hospital discharge was 25.8%. When the MEWS was divided into three risk groups (low: ≤2, intermediate: 3–4, high: ≥5), the distribution of the low-risk MEWS group decreased at each time point before cardiac arrest. However, even 8 hours prior to cardiac arrest, 45.3% of patients were still in the low MEWS group. The MEWS was associated with in-hospital mortality at each time point. However, increasing MEWS value from MEWS₂₄ to MEWS₈ was not associated with in-hospital mortality [OR 1.24 (0.77–1.97), p = 0.38].

Conclusions

About half of patients were still in low MEWS group 8 hours prior to cardiac arrest and an increasing MEWS only occurred in 46.8% of patients, suggesting that monitoring the MEWS alone is not enough to predict cardiac arrest.

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.

Safety, feasibility, and outcomes of induced hypothermia therapy following in-hospital cardiac arrest-evaluation of a large prospective registry*

OBJECTIVES

Despite a lack of randomized trials, practice guidelines recommend that mild induced hypothermia be considered for comatose survivors of in-hospital cardiac arrest. This study describes the safety, feasibility, and outcomes of mild induced hypothermia treatment following in-hospital cardiac arrest.

DESIGN

Prospective, observational, registry-based study.

SETTING

Forty-six critical care facilities in eight countries in Europe and the United States reporting in the Hypothermia Network Registry and the International Cardiac Arrest Registry.

PATIENTS

A total of 663 patients with in-hospital cardiac arrest and treated with mild induced hypothermia were included between January 2004 and February 2012.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A cerebral performance category of 1 or 2 was considered a good outcome. At hospital discharge 41% of patients had a good outcome. At median 6-month follow-up, 34% had a good outcome. Among in-hospital deaths, 52% were of cardiac causes and 44% of cerebral cause. A higher initial body temperature was associated with reduced odds of a good outcome (odds ratio, 0.79; 95% CI, 0.68-0.92). Adverse events were common; bleeding requiring transfusion (odds ratio, 0.56; 95% CI, 0.31-1.00) and sepsis (odds ratio, 0.52; 95% CI, 0.30-0.91) were associated with reduced odds for a good outcome.

CONCLUSIONS

In this registry study of an in-hospital cardiac arrest population treated with mild induced hypothermia, we found a 41% good outcome at hospital discharge and 34% at follow-up. Infectious complications occurred in 43% of cases, and 11% of patients required a transfusion for bleeding. The majority of deaths were of cardiac origin.

Using risk prediction tools in survivors of in-hospital cardiac arrest

In-hospital cardiac arrests are common and associated with poor outcomes. Predicting the likelihood of favorable neurological survival following resuscitation from an in-hospital cardiac arrest could provide important information for physicians and families. In this article, we review the literature regarding predictors of survival following in-hospital cardiac arrest. Specifically, we describe the Cardiac Arrest Survival Postresuscitation In-hospital (CASPRI) score that was recently developed and validated using data from the Get With the Guidelines-Resuscitation registry. The CASPRI score includes 11 predictor variables: age, initial cardiac arrest rhythm, defibrillation time, baseline neurological status, duration of resuscitation, mechanical ventilation, renal insufficiency, hepatic insufficiency, sepsis, malignancy, and hypotension. The score is simple to use at the bedside, has excellent discrimination and calibration, and provides robust estimates of the probability of favorable neurological survival after an in-hospital cardiac arrest. Thus, CASPRI may be valuable in establishing expectations by physicians and families in the critical period after these high-risk events.

The fully automatic external cardioverter defibrillator: reality of a new meaningful scenario for in-hospital cardiac arrests

Sudden cardiac death is an unresolved problem which causes significant mortality and morbidity in both the community and in-hospital setting. Cardiac arrest is often caused by ventricular tachyarrhythmias which may be mostly interrupted by cardioversion or defibrillation. The single most critical factor for survival is the response time. Over the last 30 years, there have been virtually no procedural changes in the way hospitals address in-hospital resuscitation. A unique device has been developed that eliminates human intervention and assures defibrillation therapy is administered in seconds. This is accomplished with a fully automatic, external bedside monitor defibrillator designed to be prophylactically attached to hospitalized patients at risk of ventricular tachyarrhythmia. The safety and efficacy of the device has been demonstrated in multicenter US and European trials. Thus, this device allows a new scenario which may increase survival and enables meaningful redistribution of health resources.

In-hospital cardiac arrest: can we change something?

Cardiac arrest is classified as 'in-hospital' if it occurs in a hospitalised patient who had a pulse at the time of admission. A probability of patient's survival until hospital discharge is very low. The reasons for this are old age, multiple co-morbidity of patients, late recognition of cardiac arrest, poor knowledge about basic life support algorithm, insufficient equipment, absence of qualified resuscitation teams (RTs) and poor organization.The aim of this study was to demonstrate characteristics of in-hospital cardiac arrests and resuscitation measures in University Hospital Osijek. We analysed retrospectively all resuscitation procedures data where anaesthesiology RTs provided cardiopulmonary resuscitation (CPR) during 5-year period.We analysed 309 in-hospital resuscitation attempts with complete documentation. Victims of cardiac arrest were principally elderly patients, neurological (30.4 %), surgical (25.24 %) and neurosurgical patients (15.2 %) with many associated severe diseases. In 85.6 % of the cases, resuscitation was initiated by ward personnel and RTs arrived within 5 min in 67 % of the cases. However, in 14.6 % of the cases resuscitation measures had not been started before RT arrival. We found statistical correlation between lower initial survival rates and length of hospital stay (p = 0.001), presence of cerebral ischemia (p = 0.026) or cardiomyopathy (p = 0.004) and duration of CPR (p = 0.041). Initial survival was very low (14.6 %), and full recovery was accomplished in only eight patients out of 309 (2.59 %).Identification of terminal chronic patients in which the CPR is not reasonable, a better organisation and ward personnel education can contribute to better overall success.

Correlations between first documented cardiac rhythms and preceding telemetry in patients with code blue events

BACKGROUND

Among in-hospital cardiac arrest (IHCA) patients, the first cardiac rhythm documented on resuscitation records (FDR) is often used as a surrogate for arrest etiology. Although the FDR generally represents the electrical activity at the time of cardiopulmonary resuscitation initiation, it may not be the ideal rhythm to infer the arrest etiology. We hypothesized that a rhythm present earlier-at the time of the code blue call-would frequently differ from the FDR, because the FDR might represent the later stage of a progressive cardiopulmonary process.

OBJECTIVE

To evaluate agreement between FDR and telemetry rhythm at the time of code blue call.

DESIGN

Cross-sectional study.

SETTING

A 750-bed adult tertiary care hospital and a 240-bed adult inner city community hospital.

PATIENTS

Adult general ward patients monitored on the hospital's telemetry system during the 2 minutes prior to a code blue call for IHCA.

INTERVENTION

None.

MEASUREMENTS

Agreement between FDR and telemetry rhythm.

RESULTS

Among 69 IHCAs, agreement between FDR and telemetry was 65% (kappa = 0.37). Among 17 events with FDRs of ventricular tachyarrhythmia (VTA), telemetry showed VTA in 12 (71%) and other organized rhythms in 5 (29%). Among 12 events with first documented rhythms of asystole, telemetry showed asystole in 3 (25%), VTA in 1 (8%), and other organized rhythms in 8 (67%).

CONCLUSIONS

The FDR had only fair agreement with the telemetry rhythm at the time of code blue call. The telemetry rhythm may be a useful adjunct to the FDR when investigating arrest etiology.

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

OBJECTIVE

Since the introduction of telemetry over a half century ago, it has expanded to various units and wards within health care institutions outside of the traditional critical care setting. Little is known on whether routine telemetry use is beneficial in this patient population. The aim of this study was to determine the impact of telemetry monitoring on survival of in-hospital cardiac arrests in patients admitted to non-critical care units.

METHODS

A retrospective study of cardiac arrests in patients admitted to non-critical care units within the Winnipeg Regional Health Authority from 2002 to 2006 inclusive was performed. Baseline demographic, cardiac arrest, and outcome data were collected.

RESULTS

Of the total 668 patients, the mean age was 70±14 years with 404 (61%) males. Patients presenting with asystole or pulseless electrical activity (PEA) demonstrated an increased mortality as compared to those presenting with ventricular tachycardia (VT) or ventricular fibrillation (VF). Overall, 268 of 668 patients (40%) survived their initial arrest, 66 (10%) survived to hospital discharge and 49 (7%) survived transfer to another facility. Patients on telemetry vs. no telemetry had higher survival rates immediately following cardiac arrest (66% vs. 34%, OR=3.67, p=0.02), as well as higher survival to hospital discharge (30% vs. 6%, OR=7.17, p=0.01). Finally, patients with cardiac arrest during the night and early morning benefited proportionally the greatest from telemetry use.

CONCLUSION

Regardless of whether cardiac arrest was witnessed or unwitnessed, telemetry use was an independent and strong predictor of survival to hospital discharge.

Factors influencing nurses' decisions to activate medical emergency teams

AIMS AND OBJECTIVES

To evaluate the relationship between nurse demographics and correct identification of clinical situations warranting specific nursing actions, including activation of the medical emergency team.

BACKGROUND

If abnormal physiology is left untreated, the patient may develop cardiac arrest. Nurses in general wards are those who perceive any clinical deterioration in patients.

DESIGN

A descriptive, quantitative design was selected.

METHODS

An anonymous survey with 13 multiple choice questions was distributed to 150 randomly selected nurses working in general medical and surgical wards of a large tertiary hospital in Athens, Greece. After explanation of the purposes of the study, 94 nurses (response ratio: 62%) agreed to respond to the questionnaire.

RESULTS

Categories with the greatest nursing concern were patients with heart rate<40/minute, an atypical thoracic pain, foreign body airway obstruction and bronchial secretions, respiratory rate<5/minute and heart rate=100/minute. However, almost 50% of nurses were able to accurately identify the critical nursing action for patients with respiratory rate<4/minute, 72% for patients with airway obstruction and 73% for patients with chest pain. Nurses who had graduated from a four-year educational programme identified clinical situations that necessitated medical emergency team activation in a significantly higher rate and also scored significantly higher in questions concerning clinical evaluation than nurses who had graduated from a two-year educational programme.

CONCLUSION

Activation of the medical emergency team is influenced by factors such as level of education and cardiopulmonary resuscitation courses attendance.

RELEVANCE TO CLINICAL PRACTICE

Graduating from a four-year educational programme helps nurses identify emergencies. However, irrespective of the educational programme they have followed, undertaking a basic life support or advanced life support provider course is critical as it helps them identify cardiac or respiratory emergencies.

[Post-cardiac arrest syndrome in children]

The occurrence of post-cardiac arrest syndrome may lead to death in some children who have recovered from a cardiac arrest. The post-cardiac arrest syndrome includes systemic ischaemia/reperfusion response, brain injury, myocardial dysfunction, and persistence of the precipitating pathology. The main cause of death is brain injury. Management includes strictly control of ventilation, oxygen therapy and haemodynamics associated with protection of the brain against any secondary injury: management of seizures, control of glycaemia and central temperature. Mild hypothermia should be considered in comatose children after cardiac arrest.

Outcomes of mild therapeutic hypothermia after in-hospital cardiac arrest

BACKGROUND

Although the benefits of mild therapeutic hypothermia (MTH) in selected patients after out-of-hospital cardiac arrest have been consistently demonstrated, no controlled trial of MTH in selected patients after in-hospital cardiac arrest (IHCA) has been published. We sought to assess the benefit of MTH after IHCA in patients meeting our institutions IHCA MTH inclusion criteria.

METHODS

A retrospective, historical control study was performed. During the 3-year period before and after the 2006 MTH protocol implementation at our institution, we identified a total of 118 patients admitted to our Medical Intensive Care Unit after resuscitation from an IHCA. Two blinded investigators identified all patients meeting our institutions MTH protocol inclusion criteria and the patients in each time period were compared. The primary outcome was discharge with good neurological function.

RESULTS

33 IHCA patients met MTH protocol inclusion criteria; 16 patients were admitted prior to MTH protocol implementation and thus were not treated with MTH post arrest while 17 patients were admitted after implementation and were all treated with MTH post arrest. 91% of patients had an arrest rhythm of asystole or pulseless electrical activity. Good neurological function at discharge was found in 24% of MTH patients and 31% of controls (P = .62).

CONCLUSIONS

No difference in neurological outcome at discharge was detected in predominantly non-shockable IHCA patients treated with MTH. This finding, if confirmed with further study, may define a population of patients for whom this costly and resource intensive therapy should be withheld.

Derivation of a cardiac arrest prediction model using ward vital signs*

OBJECTIVE

Rapid response team activation criteria were created using expert opinion and have demonstrated variable accuracy in previous studies. We developed a cardiac arrest risk triage score to predict cardiac arrest and compared it to the Modified Early Warning Score, a commonly cited rapid response team activation criterion.

DESIGN

A retrospective cohort study.

SETTING

An academic medical center in the United States.

PATIENTS

All patients hospitalized from November 2008 to January 2011 who had documented ward vital signs were included in the study. These patients were divided into three cohorts: patients who suffered a cardiac arrest on the wards, patients who had a ward to intensive care unit transfer, and patients who had neither of these outcomes (controls).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Ward vital signs from admission until discharge, intensive care unit transfer, or ward cardiac arrest were extracted from the medical record. Multivariate logistic regression was used to predict cardiac arrest, and the cardiac arrest risk triage score was calculated using the regression coefficients. The model was validated by comparing its accuracy for detecting intensive care unit transfer to the Modified Early Warning Score. Each patient's maximum score prior to cardiac arrest, intensive care unit transfer, or discharge was used to compare the areas under the receiver operating characteristic curves between the two models. Eighty-eight cardiac arrest patients, 2,820 intensive care unit transfers, and 44,519 controls were included in the study. The cardiac arrest risk triage score more accurately predicted cardiac arrest than the Modified Early Warning Score (area under the receiver operating characteristic curve 0.84 vs. 0.76; p = .001). At a specificity of 89.9%, the cardiac arrest risk triage score had a sensitivity of 53.4% compared to 47.7% for the Modified Early Warning Score. The cardiac arrest risk triage score also predicted intensive care unit transfer better than the Modified Early Warning Score (area under the receiver operating characteristic curve 0.71 vs. 0.67; p < .001).

CONCLUSIONS

The cardiac arrest risk triage score is simpler and more accurately detected cardiac arrest and intensive care unit transfer than the Modified Early Warning Score. Implementation of this tool may decrease rapid response team resource utilization and provide a better opportunity to improve patient outcomes than the modified early warning score.

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.

Predicting cardiac arrest on the wards: a nested case-control study

BACKGROUND

Current rapid response team activation criteria were not statistically derived using ward vital signs, and the best vital sign predictors of cardiac arrest (CA) have not been determined. In addition, it is unknown when vital signs begin to accurately detect this event prior to CA.

METHODS

We conducted a nested case-control study of 88 patients experiencing CA on the wards of a university hospital between November 2008 and January 2011, matched 1:4 to 352 control subjects residing on the same ward at the same time as the case CA. Vital signs and Modified Early Warning Scores (MEWS) were compared on admission and during the 48 h preceding CA.

RESULTS

Case patients were older (64 ± 16 years vs 58 ± 18 years; P = .002) and more likely to have had a prior ICU admission than control subjects (41% vs 24%; P = .001), but had similar admission MEWS (2.2 ± 1.3 vs 2.0 ± 1.3; P = .28). In the 48 h preceding CA, maximum MEWS was the best predictor (area under the receiver operating characteristic curve [AUC] 0.77; 95% CI, 0.71-0.82), followed by maximum respiratory rate (AUC 0.72; 95% CI, 0.65-0.78), maximum heart rate (AUC 0.68; 95% CI, 0.61-0.74), maximum pulse pressure index (AUC 0.61; 95% CI, 0.54-0.68), and minimum diastolic BP (AUC 0.60; 95% CI, 0.53-0.67). By 48 h prior to CA, the MEWS was higher in cases (P = .005), with increasing disparity leading up to the event.

CONCLUSIONS

The MEWS was significantly different between patients experiencing CA and control patients by 48 h prior to the event, but includes poor predictors of CA such as temperature and omits significant predictors such as diastolic BP and pulse pressure index.

[In-hospital emergencies at a surgical university hospital]

BACKGROUND

Emergency treatment and resuscitation within hospitals are managed by so-called medical emergency teams (MET). The present study examined the circumstances, number, initial treatment and further hospital course of in-hospital emergency cases at a level 1 university hospital.

METHODS

A retrospective study of in-hospital emergencies on the surgical wards of a university hospital including all non-intensive care areas from January 2007 to June 2010 was carried out. A self-developed documentation protocol which was introduced in 2006 was used by the MET to document general patient characteristics and details of the emergency treatment. These data included the place where the emergency situation arose, the patient's assignment to a surgical discipline, a detailed description of the emergency situation, the effectiveness of basic life support measures as well as the further hospital course of the patient.

RESULTS

A total of 235 emergency cases were documented within the study period of 3.5 years. The frequency of in-hospital emergencies was 4/1,000 admitted patients per year. Cardiac arrest was encountered in 31,5%. Out of all patients 54,5% were admitted to an intensive care unit.

CONCLUSION

The tasks of a MET at a surgical university hospital go beyond mere cardiopulmonary resuscitation. Emergency cases within the full spectrum of perioperative complications are encountered. Further multicenter studies with standardized protocols are required to analyze the management of German in-hospital emergencies.