Resuscitation in the hospital: circadian variation of cardiopulmonary arrest

The association between time of in hospital cardiac arrest and mortality; a retrospective analysis of two UK databases

AIMS

The incidence of in hospital cardiac arrest (IHCA) varies throughout the day. This study aimed to report the variation in incidence of IHCA, presenting rhythm and outcome based on the hour in which IHCA occurred.

METHODS

We conducted a retrospective analysis of the National Cardiac Arrest Audit (NCAA) including patients who suffered an IHCA from 1st April 2011 to 31st December 2019. We then linked the NCAA and intensive care Case Mix Programme databases to explore the effect of time of IHCA on hospital survival in the subgroup of patients admitted to intensive care following IHCA.

RESULTS

We identified 115,690 eligible patients in the NCAA database. Pulseless electrical activity was the commonest presenting rhythm (54.8%). 66,885 patients died in the immediate post resuscitation period. Overall, hospital survival in the NCAA cohort was 21.3%. We identified 13,858 patients with linked ICU admissions in the Case Mix Programme database; 37.0% survived to hospital discharge. The incidence of IHCA peaked at 06.00. Rates of return of spontaneous circulation, survival to hospital discharge and good neurological outcome were lowest between 05.00 and 07.00. Among those admitted to ICU, no clear diurnal variation in hospital survival was seen in the unadjusted or adjusted analysis. This pattern was consistent across all presenting rhythms.

CONCLUSIONS

We observed higher rates of IHCA, and poorer outcomes at night. However, in those admitted to ICU, this variation was absent. This suggests patient factors and processes of care issues contribute to the variation in IHCA seen throughout the day.

Comparison of Circadian Variation for In-Hospital Versus Out-of-Hospital Sudden Cardiac Arrest Survivors

Several studies have reported circadian periodicity of sudden cardiac arrest (SCA). It remains unclear to what extent this circadian rhythm is influenced by variation in patients' activities. One way to elucidate this is to compare patients with out-of-hospital cardiac arrests (OHCAs) with those with in-hospital cardiac arrests (IHCAs). We therefore examined the presence of a circadian pattern of SCA in a large cohort of OHCA and IHCA survivors. A total of 1,433 consecutive survivors of SCA in the Pittsburgh area from 2002 to 2012 were included. Patient demographics, including clinical histories and details of SCA, were collected. The distribution of SCA throughout the day was tested for differences using the chi-square test. Of the 1,224 patients analyzed, 706 had IHCA and 518 OHCA. We observed a nadir of SCA in the nighttime hours between 12 a.m. and 6 a.m. in both IHCA and OHCA groups (p <0.001), although this pattern was more blunted in the IHCA group. Patients who had an SCA in the nighttime window had more co-morbidities (p = 0.01). The circadian pattern was noted to be absent in patients with higher co-morbidity burden in IHCA only. In conclusion, the typical pattern of nighttime nadir in SCA is observed in patients with both OHCA and IHCA but is blunted in the hospital and especially in sicker patients. This suggests a common mechanistic pathway of SCA transcending differences in physical activities of patients and a difference in how co-morbidities interact with the timing of SCA in the inpatient setting.

Circadian Rhythms in Sudden Cardiac Arrest: A Review

BACKGROUND

Sudden cardiac arrest (SCA) is a serious public health issue caused by the cessation of cardiac electrical and mechanical activity. Despite advances in pedestrian lifesaving technologies like defibrillators, the SCA mortality rate remains high, and survivors are at risk of suffering ischemic injury to various organs. Understanding the contributing factors for SCA is essential for improving morbidity and mortality. One factor capable of influencing SCA incidence and survival is the time of day at which SCA occurs.

OBJECTIVES

This review focused on the effect of time of day on SCA incidence, survival rate, and survival to discharge over the past 30 years and the role of age, sex, and SCA location in modulating the timing of SCA.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews criteria guided this review. Four databases (PubMed, Cochrane Libraries, Scopus, and Cumulative Index to Nursing and Allied Health Literature) were queried for research reports or articles addressing time of day and cardiac arrest, which were subsequently screened by the authors for inclusion in this analysis.

RESULTS

A total of 48 articles were included in the final analysis. This analysis showed a bimodal SCA distribution with a primary peak in the morning and a secondary peak in the afternoon; these peaks were dependent on age (older persons), sex (more frequent in males), and the location of occurrence (out-of-hospital cardiac arrest vs. in-hospital cardiac rest). Survival following SCA was lowest between midnight and 06:00 a.m.

DISCUSSION

The circadian rhythm likely plays an important role in the time-of-day-dependent pattern that is evident in both the incidence of and survival following SCA. There is a renewed call for nursing research to examine or address circadian rhythm as an element in studies involving older adults and activities affecting cardiovascular or respiratory parameters.

Spatial-time analysis of cardiovascular emergency medical requests: enlightening policy and practice

Background

Response time to cardiovascular emergency medical requests is an important indicator in reducing cardiovascular disease (CVD) -related mortality. This study aimed to visualize the spatial-time distribution of response time, scene time, and call-to-hospital time of these emergency requests. We also identified patterns of clusters of CVD-related calls.

Methods

This cross-sectional study was conducted in Mashhad, north-eastern Iran, between August 2017 and December 2019. The response time to every CVD-related emergency medical request call was computed using spatial and classical statistical analyses. The Anselin Local Moran’s I was performed to identify potential clusters in the patterns of CVD-related calls, response time, call-to-hospital arrival time, and scene-to-hospital arrival time at small area level (neighborhood level) in Mashhad, Iran.

Results

There were 84,239 CVD-related emergency request calls, 61.64% of which resulted in the transport of patients to clinical centers by EMS, while 2.62% of callers (a total of 2218 persons) died before EMS arrival. The number of CVD-related emergency calls increased by almost 7% between 2017 and 2018, and by 19% between 2017 and 2019. The peak time for calls was between 9 p.m. and 1 a.m., and the lowest number of calls were recorded between 3 a.m. and 9 a.m. Saturday was the busiest day of the week in terms of call volume. There were statistically significant clusters in the pattern of CVD-related calls in the south-eastern region of Mashhad. Further, we found a large spatial variation in scene-to-hospital arrival time and call-to-hospital arrival time in the area under study.

Conclusion

The use of geographical information systems and spatial analyses in modelling and quantifying EMS response time provides a new vein of knowledge for decision makers in emergency services management. Spatial as well as temporal clustering of EMS calls were present in the study area. The reasons for clustering of unfavorable time indices for EMS response requires further exploration. This approach enables policymakers to design tailored interventions to improve response time and reduce CVD-related mortality.

Circadian variation of in-hospital cardiac arrest

BACKGROUND

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

AIM OF THE STUDY

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Automated sleep apnea detection from cardio-pulmonary signal using bivariate fast and adaptive EMD coupled with cross time-frequency analysis

Sleep apnea is a sleep related pathology in which breathing or respiratory activity of an individual is obstructed, resulting in variations in the cardio-pulmonary (CP) activity. The monitoring of both cardiac (heart rate (HR)) and pulmonary (respiration rate (RR)) activities are important for the automated detection of this ailment. In this paper, we propose a novel automated approach for sleep apnea detection using the bivariate CP signal. The bivariate CP signal is formulated using both HR and RR signals extracted from the electrocardiogram (ECG) signal. The approach consists of three stages. First, the bivariate CP signal is decomposed into intrinsic mode functions (IMFs) and residuals for both HR and RR channels using bivariate fast and adaptive empirical mode decomposition (FAEMD). Second, the features are extracted using time-domain analysis, spectral analysis, and time-frequency domain analysis of IMFs from CP signal. The time-frequency domain features are computed from the cross time-frequency matrices of IMFs of CP signal. The cross time-frequency matrix of each IMF is evaluated using the Stockwell (S)-transform. Third, the support vector machine (SVM) and the random forest (RF) classifiers are used for automated detection of sleep apnea with the features from the bivariate CP signal. Our proposed approach has demonstrated an average sensitivity and specificity of 82.27% and 78.67%, respectively for sleep apnea detection using the 10-fold cross-validation method. The approach has yielded an average sensitivity and specificity of 73.19% and 73.13%, respectively for the subject-specific cross-validation. The performance of the approach was compared with other CPC features used for the detection of sleep apnea.

Does the Time of Solitary Rapid Response Team Call Affect Patient Outcome?

Objective

The study aimed to evaluate the effect of a single after-hours rapid response team (RRT) calls on patient outcome.

Design

A retrospective cohort study of RRT-call data over a 3-year period.

Setting

A 600-bedded, tertiary referral, public university hospital.

Participants

All adult patients who had a single RRT-call during their hospital stay.

Intervention

None.

Main outcomes measures

The primary outcome was to compare all-cause in-hospital mortality. The secondary outcomes were to study the hourly variation of RRT-calls and the mortality rate.

Results

Of the total 5,108 RRT-calls recorded, 1,916 patients had a single RRT-call. Eight hundred and sixty-one RRT-calls occurred during work-hours (08:00-17:59 hours) and 1,055 during after-hours (18:00-7:59). The all-cause in-hospital mortality was higher (15.07% vs 9.75%, OR 1.64, 95% CI 1.24-2.17, p value 0.001) in patients who had an after-hours RRT-call. This difference remained statistically significant after multivariate regression analysis (OR 1.50, 95% CI 1.11-2.01, p value 0.001). We noted a lower frequency of hourly RRT-calls after-hours but were associated with higher hourly mortality rates. There was no difference in outcomes for patients who were admitted to ICU post-RRT-call.

Conclusion

Patients having an after-hour RRT-call appear to have a higher risk for hospital mortality. No causal mechanism could be identified other than a decrease in hourly RRT usage during after-hours.

How to cite this article

Singh MY, Vegunta R, Karpe K, Rai S. Does the Time of Solitary Rapid Response Team Call Affect Patient Outcome? Indian J Crit Care Med 2020;24(1):38-43.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes and modifiable resuscitative characteristics amongst pan-Asian out-of-hospital cardiac arrest occurring at night

Studies are divided on the effect of day-night temporal differences on clinical outcomes in out-of-hospital cardiac arrest (OHCA). This study aimed to elucidate any differences in OHCA survival between day and night occurrence, and the factors associated with differences in survival.This was a prospective, observational study of OHCA cases across multinational Pan-Asian sites. Cases were divided according to time call received by dispatch centers into day (0700H-1900H) and night (1900H-0659H). Primary outcome was 30-day survival. Secondary outcomes were prehospital and hospital modifiable resuscitative characteristics.About 22,501 out of 55,881 cases occurred at night. Night cases were less likely to be witnessed (40.2% vs. 43.1%, P < .001), more likely to occur at home (32.5% vs. 29%, P < .001), had non-shockable initial rhythms (90.8% vs. 89.4%, P < .001), lower bystander CPR rates (36.2 vs. 37.6%, P = .001), lower bystander AED application rate (0.3% vs. 0.7%, P < .001), lower rates of prehospital defibrillation (13% vs. 14.4%, P < .001), and were less likely to receive prehospital adrenaline (9.8% vs. 11%, P < .001). 30-day survival at night was lower with an adjusted odds ratio of 0.79 (95% CI 0.73-0.86, P < .001). On multivariate logistic regression, occurrence at night was associated with decreased provision of bystander CPR, bystander AED application, and prehospital adrenaline.30-day survival was worse in OHCA occurring at night. There were circadian patterns in incidence. Bystander CPR and bystander AED application were significantly lower at night in multivariate analysis. This would at least partially explain the decreased survival at night.

Continuous chest compression versus interrupted chest compression for cardiopulmonary resuscitation of non-asphyxial out-of-hospital cardiac arrest

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a major cause of death worldwide. Cardiac arrest can be subdivided into asphyxial and non asphyxial etiologies. An asphyxia arrest is caused by lack of oxygen in the blood and occurs in drowning and choking victims and in other circumstances. A non asphyxial arrest is usually a loss of functioning cardiac electrical activity. Cardiopulmonary resuscitation (CPR) is a well-established treatment for cardiac arrest. Conventional CPR includes both chest compressions and 'rescue breathing' such as mouth-to-mouth breathing. Rescue breathing is delivered between chest compressions using a fixed ratio, such as two breaths to 30 compressions or can be delivered asynchronously without interrupting chest compression. Studies show that applying continuous chest compressions is critical for survival and interrupting them for rescue breathing might increase risk of death. Continuous chest compression CPR may be performed with or without rescue breathing.

OBJECTIVES

To assess the effects of continuous chest compression CPR (with or without rescue breathing) versus conventional CPR plus rescue breathing (interrupted chest compression with pauses for breaths) of non-asphyxial OHCA.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1 2017); MEDLINE (Ovid) (from 1985 to February 2017); Embase (1985 to February 2017); Web of Science (1985 to February 2017). We searched ongoing trials databases including controlledtrials.com and clinicaltrials.gov. We did not impose any language or publication restrictions.

SELECTION CRITERIA

We included randomized and quasi-randomized studies in adults and children suffering non-asphyxial OHCA due to any cause. Studies compared the effects of continuous chest compression CPR (with or without rescue breathing) with interrupted CPR plus rescue breathing provided by rescuers (bystanders or professional CPR providers).

DATA COLLECTION AND ANALYSIS

Two authors extracted the data and summarized the effects as risk ratios (RRs), adjusted risk differences (ARDs) or mean differences (MDs). We assessed the quality of evidence using GRADE.

MAIN RESULTS

We included three randomized controlled trials (RCTs) and one cluster-RCT (with a total of 26,742 participants analysed). We identified one ongoing study. While predominantly adult patients, one study included children. Untrained bystander-administered CPRThree studies assessed CPR provided by untrained bystanders in urban areas of the USA, Sweden and the UK. Bystanders administered CPR under telephone instruction from emergency services. There was an unclear risk of selection bias in two trials and low risk of detection, attrition, and reporting bias in all three trials. Survival outcomes were unlikely to be affected by the unblinded design of the studies.We found high-quality evidence that continuous chest compression CPR without rescue breathing improved participants' survival to hospital discharge compared with interrupted chest compression with pauses for rescue breathing (ratio 15:2) by 2.4% (14% versus 11.6%; RR 1.21, 95% confidence interval (CI) 1.01 to 1.46; 3 studies, 3031 participants).One trial reported survival to hospital admission, but the number of participants was too low to be certain about the effects of the different treatment strategies on survival to admission(RR 1.18, 95% CI 0.94 to 1.48; 1 study, 520 participants; moderate-quality evidence).There were no data available for survival at one year, quality of life, return of spontaneous circulation or adverse effects.There was insufficient evidence to determine the effect of the different strategies on neurological outcomes at hospital discharge (RR 1.25, 95% CI 0.94 to 1.66; 1 study, 1286 participants; moderate-quality evidence). The proportion of participants categorized as having good or moderate cerebral performance was 11% following treatment with interrupted chest compression plus rescue breathing compared with 10% to 18% for those treated with continuous chest compression CPR without rescue breathing. CPR administered by a trained professional In one trial that assessed OHCA CPR administered by emergency medical service professionals (EMS) 23,711 participants received either continuous chest compression CPR (100/minute) with asynchronous rescue breathing (10/minute) or interrupted chest compression with pauses for rescue breathing (ratio 30:2). The study was at low risk of bias overall.After OHCA, risk of survival to hospital discharge is probably slightly lower for continuous chest compression CPR with asynchronous rescue breathing compared with interrupted chest compression plus rescue breathing (9.0% versus 9.7%) with an adjusted risk difference (ARD) of -0.7%; 95% CI (-1.5% to 0.1%); moderate-quality evidence.There is high-quality evidence that survival to hospital admission is 1.3% lower with continuous chest compression CPR with asynchronous rescue breathing compared with interrupted chest compression plus rescue breathing (24.6% versus 25.9%; ARD -1.3% 95% CI (-2.4% to -0.2%)).Survival at one year and quality of life were not reported.Return of spontaneous circulation is likely to be slightly lower in people treated with continuous chest compression CPR plus asynchronous rescue breathing (24.2% versus 25.3%; -1.1% (95% CI -2.4 to 0.1)), high-quality evidence.There is high-quality evidence of little or no difference in neurological outcome at discharge between these two interventions (7.0% versus 7.7%; ARD -0.6% (95% CI -1.4 to 0.1).Rates of adverse events were 54.4% in those treated with continuous chest compressions plus asynchronous rescue breathing versus 55.4% in people treated with interrupted chest compression plus rescue breathing compared with the ARD being -1% (-2.3 to 0.4), moderate-quality evidence).

AUTHORS' CONCLUSIONS

Following OHCA, we have found that bystander-administered chest compression-only CPR, supported by telephone instruction, increases the proportion of people who survive to hospital discharge compared with conventional interrupted chest compression CPR plus rescue breathing. Some uncertainty remains about how well neurological function is preserved in this population and there is no information available regarding adverse effects.When CPR was performed by EMS providers, continuous chest compressions plus asynchronous rescue breathing did not result in higher rates for survival to hospital discharge compared to interrupted chest compression plus rescue breathing. The results indicate slightly lower rates of survival to admission or discharge, favourable neurological outcome and return of spontaneous circulation observed following continuous chest compression. Adverse effects are probably slightly lower with continuous chest compression.Increased availability of automated external defibrillators (AEDs), and AED use in CPR need to be examined, and also whether continuous chest compression CPR is appropriate for paediatric cardiac arrest.

Emergency Neurological Life Support: Resuscitation Following Cardiac Arrest

Cardiac arrest is the most common cause of death in North America. Neurocritical care interventions, including targeted temperature management (TTM), have significantly improved neurological outcomes in patients successfully resuscitated from cardiac arrest. Therefore, resuscitation following cardiac arrest was chosen as an emergency neurological life support protocol. Patients remaining comatose following resuscitation from cardiac arrest should be considered for TTM. This protocol will review induction, maintenance, and re-warming phases of TTM, along with management of TTM side effects. Aggressive shivering suppression is necessary with this treatment to ensure the maintenance of a target temperature. Ancillary testing, including electrocardiography, computed tomography and/or magnetic resonance imaging of the brain, continuous electroencephalography monitoring, and correction of electrolyte, blood gas, and hematocrit changes, are also necessary to optimize outcomes.

Frequency and survival pattern of in-hospital cardiac arrests: The impacts of etiology and timing

OBJECTIVE

Define the frequency and survival pattern of cardiac arrests in relation to the hospital day of event and etiology of arrest.

SUBJECT AND METHODS

Retrospective cohort study of adult in-hospital cardiac arrests between July 1, 2005, and June 30, 2013, that were classified by etiology of deterioration. Arrests were divided based on hospital day (HD) of event (HD1, HD2-7, HD>7 days), and analysis of frequency was performed. The primary outcome of survival to discharge and secondary outcomes of return of spontaneous circulation (ROSC) and favorable neurological outcomes were compared using multivariable logistic regression analysis.

RESULTS

A total of 627 cases were included, 193 (30.8%) cases in group HD1, 206 (32.9%) in HD2-7, and 228 (36.4%) in HD>7. Etiology of arrest demonstrated variability across the groups (p<0.001). Arrests due to ventilation issues increased in frequency with longer hospitalization (p<0.001) while arrests due to dysrhythmia had the opposite trend (p=0.014). Rates of survival to discharge (p=0.038) and favorable neurological outcomes (p=0.002) were lower with increasing hospital days while ROSC was not different among the groups (p=0.183). Survival was highest for HD1 (HD1: 38.9% [95% CI, 32.0-45.7%], p=0.002 vs HD2-7: 34.0% [95% CI, 27.5-40.4%], p<0.001 vs HD>7: 27.2% [95% CI, 21.4-33.0%], p<0.001).

CONCLUSIONS

The etiology of cardiac arrests varies in frequency as length of hospitalization increases. Survival rates and favorable neurological outcomes are lower for in-hospital arrests occurring later in the hospitalization, even when adjusted for age, sex, and location of event. Understanding these issues may help with focusing therapies and accurate prognostication.

A retrospective study of in-hospital cardiac arrest

Aim

In-hospital cardiac arrest is an important issue in health care today. Data regarding in-hospital cardiac arrest in Japan is limited. In Australia and the USA, the Rapid Response System has been implemented in many institutions and data regarding in-hospital cardiac arrest are collected to evaluate the efficacy of the Rapid Response System. This is a multicenter retrospective survey of in-hospital cardiac arrest, providing data before implementing a Rapid Response System.

Methods

Ten institutions planning to introduce a Rapid Response System were recruited to collect in-hospital cardiac arrest data. The Institutional Review Board at each participating institution approved this study. Data for patients admitted at each institution from April 1, 2011 until March 31, 2012 were extracted using the three keywords "closed-chest compression", "epinephrine", and "defibrillation". Patients under 18 years old, or who suffered cardiac arrest in the emergency room or the intensive care unit were excluded.

Results

A total of 228 patients in 10 institutions were identified. The average age was 73 ± 13 years. Males represented 64% of the patients (82/146). Overall survival after in-hospital cardiac arrest was 7% (16/228). Possibly preventable cardiac arrests represented 15% (33/228) of patients, with medical safety issues identified in 8% (19/228). Vital sign abnormalities before cardiac arrest were observed in 63% (138/216) of patients.

Conclusions

Approximately 60% of patients had abnormal vital signs before cardiac arrest. These patients may have an improved clinical outcome by implementing a Rapid Response System.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Regional variation in the incidence and outcomes of in-hospital cardiac arrest in the United States

BACKGROUND

Regional variation in the incidence and outcomes of in-hospital cardiac arrest (IHCA) is not well studied and may have important health and policy implications.

METHODS AND RESULTS

We used the 2003 to 2011 Nationwide Inpatient Sample databases to identify patients≥18 years of age who underwent cardiopulmonary resuscitation (International Classification of Diseases, Ninth Edition, Clinical Modification procedure codes 99.60 and 99.63) for IHCA. Regional differences in IHCA incidence, survival to hospital discharge, and resource use (total hospital cost and discharge disposition among survivors) were analyzed. Of 838,465 patients with IHCA, 162,270 (19.4%) were in the Northeast, 159,581 (19.0%) were in the Midwest, 316,201 (37.7%) were in the South, and 200,413 (23.9%) were in the West. Overall IHCA incidence in the United States was 2.85 per 1000 hospital admissions. IHCA incidence was lowest in the Midwest and highest in the West (2.33 and 3.73 per 1000 hospital admissions, respectively). Compared with the Northeast, risk-adjusted survival to discharge was significantly higher in the Midwest (odds ratio, 1.33; 95% confidence interval, 1.31-1.36), South (odds ratio, 1.21; 95% confidence interval, 1.19-1.23), and West (odds ratio, 1.25; 95% confidence interval, 1.23-1.27). IHCA survival increased significantly from 2003 to 2011 in the United States and in all regions (all Ptrend<0.001). Total hospital cost was highest in the West, whereas discharge to skilled nursing facility and use of home health care among survivors was highest in the Northeast.

CONCLUSIONS

We observed significant regional variation in IHCA incidence, survival, and resource use in the United States. This variation was explained only partially by differences in patient and hospital characteristics. Further studies are needed to identify other potential factors responsible for these regional differences to improve outcomes after IHCA.

A prospective study to determine the circumstances, incidence and outcome of cardiopulmonary resuscitation in a referral hospital in India, in relation to various factors

Background and Aims:

Cardiac arrest has multifactorial aetiology and the outcome depends on timely and correct interventions. We decided to investigate the circumstances, incidence and outcome of cardiopulmonary resuscitation (CPR) at a tertiary hospital in India, in relation to various factors, including extensive basic life support and advanced cardiac life support training programme for all nurses and doctors.

Methods:

It has been over a decade and a half with periodical updates and implementation of newer guidelines prepared by various societies across the world about CPR for both in-hospital and out-of hospital cardiac arrests (IHCA and OHCA). We conducted a prospective study wherein all cardiac arrests reported in the hospital consecutively for 12 months were registered for the study and followed their survival up to 1-year. Statistical analysis was performed by using Chi-square test for significant differences in proportions applied to various parameters of the study.

Results:

The main outcome measures were; (following CPR) return of spontaneous circulation, survival for 24 h, survival from 24 h to 6 weeks or discharge, alive at 1-year. For survivors, an assessment was made about their cerebral performance and overall performance and accordingly graded. All these data were tabulated. Totally 419 arrests were reported in the hospital, out of which 413 were in-hospital arrests. Out of this 260 patients were considered for resuscitation, we had about 27 survivors at the end of 1-year follow-up (10.38%).

Conclusion:

We conclude by saying there are many factors involved in good clinical outcomes following IHCAs and these variable factors need to be researched further.

Cardiopulmonary resuscitation (CPR) plus delayed defibrillation versus immediate defibrillation for out-of-hospital cardiac arrest

BACKGROUND

Sudden cardiac arrest (SCA) is a common health problem associated with high levels of mortality. Cardiac arrest is caused by three groups of dysrhythmias: ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), pulseless electric activity (PEA) and asystole. The most common dysrhythmia found in out-of-hospital cardiac arrest (OHCA) is VF. During VF or VT, cardiopulmonary resuscitation (CPR) provides perfusion and oxygenation to the tissues, whilst defibrillation restores a viable cardiac rhythm. Early successful defibrillation is known to improve outcomes in VF/VT. However, it has been hypothesized that a period of CPR before defibrillation creates a more conducive physiological environment, increasing the likelihood of successful defibrillation. The order of priority of CPR versus defibrillation therefore remains in contention. As previous studies have remained inconclusive, we conducted a systematic review of available evidence in an attempt to draw conclusions on whether CPR plus delayed defibrillation or immediate defibrillation resulted in better outcomes in OHCA.

OBJECTIVES

To examine whether an initial one and one-half to three minutes of CPR administered by paramedics before defibrillation versus immediate defibrillation on arrival influenced survival rates, neurological outcomes or rates of return of spontaneous circulation (ROSC) in OHCA.

SEARCH METHODS

We searched the following databases: the Cochrane Central Register of Controlled trials (CENTRAL) (2013, Issue 6); MEDLINE (Ovid) (1948 to May 2013); EMBASE (1980 to May 2013); the Institute for Scientific Information (ISI) Web of Science (1980 to May 2013) and the China Academic Journal Network Publishing Database (China National Knowledge Infrastructure (CNKI), 1980 to May 2013). We included studies published in all languages. We also searched the Current Controlled Trials and Clinical Trials databases for ongoing trials. We screened the references lists of studies included in our review against the reference lists of relevant International Liaison Committee on Resuscitation (ILCOR) evidence worksheets.

SELECTION CRITERIA

Our participant group consisted of adults over 18 years of age presenting with OHCA who were in VF or pulseless VT at the time of emergency medical service (EMS) paramedic arrival. We included randomized controlled trials (RCTs) and quasi-randomized controlled trials that evaluated the effects of one and one-half to three minutes of CPR versus defibrillation as initial therapy on survival and neurological outcomes of these participants. We excluded observational and cross-over design studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data. We contacted study authors to ask for additional data when required. The risk ratio (RR) for each outcome was calculated and summarized in the meta-analysis after heterogeneity was considered. We used Review Manager software for all analyses.

MAIN RESULTS

We included four RCTs with a total of 3090 enrolled participants (one study used a cluster-randomized design). Three trials were considered to have a relatively low risk of bias, and one trial was considered to have a relatively high risk. When survival to hospital discharge was compared, 38 of 320 (11.88%) participants survived to discharge in the initial CPR plus delayed defibrillation group compared with 39 of 338 participants (11.54%) in the immediate defibrillation group (RR 1.09, 95% CI 0.54 to 2.20, Chi(2) = 10.78, degrees of freedom (df) = 5, P value 0.06, I(2) = 54%, low-quality evidence).When we compared the neurological outcome at hospital discharge (RR 1.12, 95% CI 0.65 to 1.93, low-quality evidence), the rate of return of spontaneous circulation (ROSC) (RR 0.94, 95% CI 0.77 to 1.15,low-quality evidence) and survival at one year (RR 0.77, 95% CI 0.24 to 2.49, low-quality evidence), we could not rule out the superiority of either treatment.Adverse effects were not associated with either treatment.

AUTHORS' CONCLUSIONS

Owing to the low quality of available evidence, we have been unable to determine conclusively whether immediate defibrillation and one and one-half to three minutes of CPR as initial therapy before defibrillation have similar effects on rates of return of spontaneous circulation, survival to discharge or neurological insult.We have also been unable to conclude whether either treatment approach provides a degree of superiority in OHCA.We propose that this is an area that needs further rigorous research through additional high-quality RCTs, including larger sample sizes and proper subgroup analysis.

Therapeutic hypothermia after in-hospital cardiac arrest: a critique

More than 210,000 in-hospital cardiac arrests occur annually in the United States. Use of moderate therapeutic hypothermia (TH) in comatose survivors after return of spontaneous circulation following out-of-hospital cardiac arrest (OOH-CA) caused by ventricular fibrillation or pulseless ventricular tachycardia is recommended strongly by many professional organizations and societies. The use of TH after cardiac arrest associated with nonshockable rhythms and after in-hospital cardiac arrest (IH-CA) is recommended to be considered by these same organizations and is being applied widely. The use in these latter circumstances is based on an extrapolation of the data supporting its use after out-of-hospital cardiac arrest associated with shockable rhythms. The purpose of this article is to review the limitations of existing data supporting these extended application of TH after cardiac arrest and to suggest approaches to this dilemma. The data supporting its use for OOH-CA appear to this author, and to some others, to be rather weak, and the data supporting the use of TH for IH-CA appear to be even weaker and to include no randomized controlled trials (RCTs) or supportive observational studies. The many reasons why TH might be expected to be less effective following IH-CA are reviewed. The degree of neurologic injury may be more severe in many of these cases and, thus, may not be responsive to TH as currently practiced following OOH-CA. The potential adverse consequences of the routine use of TH for IH-CA are listed and include complications associated with TH, interference with diagnostic and interventional therapy, and use of scarce personnel and financial resources. Most importantly, it inhibits the ability of researchers to conduct needed RCTs. The author believes that the proper method of providing TH in these cases needs to be better defined. Based on this analysis the author concludes that TH should not be used indiscriminantly following most cases of IH-CA, and instead clinicians should concentrate their efforts in conducting high-quality large RCTs or large-scale, well-designed prospective observation studies to determine its benefits and identify appropriate candidates.

Survival after cardiac arrest and changing task profile of the cardiac arrest team in a tertiary care center

BACKGROUND

The characteristics of in-hospital emergency response systems, survival rates, and variables associated with survival after in-hospital cardiac arrest vary significantly among medical centers worldwide. Aiming to optimize in-hospital emergency response, we performed an analysis of survival after in-hospital cardiopulmonary resuscitation and the task profile of our cardiac arrest team.

METHODS

In-hospital emergencies handled by the cardiac arrest team in the years 2004 to 2006 were analyzed retrospectively, and patient and event characteristics were tested for their associations with survival after cardiopulmonary resuscitation. The results were compared to a similar prior analysis for the years 1995 to 1997.

RESULTS

After cardiopulmonary resuscitation, the survival rate to discharge was 30.2% for the years 2004 to 2006 compared to 25.1% for the years 1995 to 1997 (difference not statistically significant). Survival after one year was 18.5 %. An increasing percentage of emergency calls not corresponding to medical emergencies other than cardiac arrest was observed.

CONCLUSIONS

The observed survival rates are considerably high to published data. We suggest that for further improvement of in-hospital emergency response systems regular training of all hospital staff members in immediate life support is essential. Furthermore, future training of cardiac arrest team members must include basic emergency response to a variety of medical conditions besides cardiac arrest.

Temporal variation of out-of-hospital cardiac arrests in an equatorial climate

OBJECTIVE

We aimed to determine whether there is a seasonal variation of out-of-hospital cardiac arrests (OHCA) in an equatorial climate, which does not experience seasonal environmental change.

METHODS

We conducted an observational prospective study looking at the occurrence of OHCA in Singapore. Included were all patients with OHCA presented to Emergency Departments across the country. We examined the monthly, daily, and hourly number of cases over a three-year period. Data was analyzed using analysis of variance (ANOVA).

RESULTS

From October, 1st 2001 to October, 14th 2004, 2428 patients were enrolled in the study. Mean age for cardiac arrests was 60.6 years with 68.0% male. Ethnic distribution was 69.5% Chinese, 15.0% Malay, 11.0% Indian, and 4.4% Others. There was no significant seasonal variation (spring/summer/fall/winter) of events (ANOVA P = 0.71), monthly variation (P = 0.88) or yearly variation (P = 0.26). We did find weekly peaks on Mondays and a circadian pattern with daily peaks from 9-10 am.

CONCLUSIONS

We did not find any discernable seasonal pattern of cardiac arrests. This contrasts with findings from temperate countries and suggests a climatic influence on cardiac arrest occurrence. We also found that sudden cardiac arrests follow a circadian pattern.

Cardiopulmonary resuscitation in older people – a review

Survival to discharge after in-hospital cardiopulmonary resuscitation (CPR) is about 20% in those aged 65–69 years, declining with advancing age to about 10% in those aged 90 years or more. There are conflicting reports on whether or not advanced age, independent of the severity of acute and chronic illness, is a determinant of outcome. Recognition that the outcome of CPR in hospital patients is often poor has prompted extensive debate regarding the appropriate use of this procedure. In particular, there has been concern about unnecessary CPR in extended-care and hospice settings. Conversely, there has also been evidence that doctors and families may be prone to underestimate the quality of life and likelihood of benefit from CPR in older people and to make resuscitation decisions without considering the preferences of older people themselves. Recent guidelines have attempted to strike a balance between ensuring patient participation whenever possible but without offering illusory choices where CPR is very unlikely to succeed.

Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly

BACKGROUND

It is unknown whether the rate of survival after in-hospital cardiopulmonary resuscitation (CPR) is improving and which characteristics of patients and hospitals predict survival.

METHODS

We examined fee-for-service Medicare data from 1992 through 2005 to identify beneficiaries 65 years of age or older who underwent CPR in U.S. hospitals. We examined temporal trends in the incidence of CPR and the rate of survival after CPR, as well as patient- and hospital-level predictors of survival to discharge.

RESULTS

We identified 433,985 patients who underwent in-hospital CPR; 18.3% of these patients (95% confidence interval [CI], 18.2 to 18.5) survived to discharge. The rate of survival did not change substantially during the period from 1992 through 2005. The overall incidence of CPR was 2.73 events per 1000 admissions; the incidence was higher among black and other nonwhite patients. The proportion of patients undergoing in-hospital CPR before death increased over time and was higher for nonwhite patients. The survival rate was lower among patients who were men, were older, had more coexisting illnesses, or were admitted from a skilled-nursing facility. The adjusted odds of survival for black patients were 23.6% lower than those for similar white patients (95% CI, 21.2 to 25.9). The association between race and survival was partially explained by hospital effects: black patients were more likely to undergo CPR in hospitals that have lower rates of post-CPR survival. Among patients surviving in-hospital CPR, the proportion of patients discharged home rather than to a health care facility decreased over time.

CONCLUSIONS

Survival after in-hospital CPR did not improve from 1992 through 2005. The proportion of in-hospital deaths preceded by CPR increased, whereas the proportion of survivors discharged home after undergoing CPR decreased. Black race was associated with higher rates of CPR but lower rates of survival after CPR.

Geographic-Time Distribution of Ambulance Calls in Singapore: Utility of Geographic Information System in Ambulance Deployment (CARE 3)

Introduction: Pre-hospital ambulance calls are not random events, but occur in patterns and trends that are related to movement patterns of people, as well as the geographical epidemiology of the population. This study describes the geographic-time epidemiology of ambulance calls in a large urban city and conducts a time demand analysis. This will facilitate a Systems Status Plan for the deployment of ambulances based on the most cost-effective deployment strategy. Materials and Methods: An observational prospective study looking at the geographic-time epidemiology of all ambulance calls in Singapore. Locations of ambulance calls were spot-mapped using Geographic Information Systems (GIS) technology. Ambulance response times were mapped and a demand analysis conducted by postal districts. Results: Between 1 January 2006 and 31 May 2006, 31,896 patients were enrolled into the study. Mean age of patients was 51.6 years (S.D. 23.0) with 60.0% male. Race distribution was 62.5% Chinese, 19.4% Malay, 12.9% Indian and 5.2% others. Trauma consisted 31.2% of calls and medical 68.8%. 9.7% of cases were priority 1 (most severe) and 70.1% priority 2 (moderate severity). Mean call receipt to arrival at scene was 8.0 min (S.D. 4.8). Call volumes in the day were almost twice those at night, with the most calls on Mondays. We found a definite geographical distribution pattern with heavier call volumes in the suburban town centres in the Eastern and Southern part of the country. We characterised the top 35 districts with the highest call volumes by time periods, which will form the basis for ambulance deployment plans. Conclusion: We found a definite geographical distribution pattern of ambulance calls. This study demonstrates the utility of GIS with despatch demand analysis and has implications for maximising the effectiveness of ambulance deployment. Keywords: Demand analysis, Despatch, Emergency Medical Services

Survey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan

PURPOSE OF THE STUDY

While the outcomes of cardiopulmonary resuscitation (CPR) for pediatric in-hospital cardiac arrest (IHCA) are reported for many regions, none is reported for Asian countries. We report the outcomes of CPR for pediatric IHCA in a tertiary medical center in Taiwan and also identify prognostic factors associated with poor outcome.

METHODS

Data were retrieved retrospectively from 2000 to 2003 and prospectively from 2004 to 2006 from our web-based registry system. We evaluated patients younger than 18 years of age who had IHCA and received CPR. The primary outcome was survival to hospital discharge, and the secondary outcomes were sustained return of spontaneous circulation (ROSC), and favorable neurological outcomes as assessed by pediatric cerebral performance categories (PCPC).

RESULTS

We identified 316 patients and the overall hospital survival was 20.9% and 16.1% had favorable neurological outcomes. Sixty-four patients ever supported with ECMO. We further analyzed 252 patients who underwent conventional CPR only and most had cardiac disease (133/252, 52.8%). The second most common preexisting condition was hematologic or oncologic disease (43/252, 17.1%). Of the 252 patients, 153 (60.7%) achieved sustained ROSC, 50 (19.8%) survived to discharge, and 39 patients (15.5%) had favorable neurological outcomes. CPR during off-work hours resulted in inferior chances of reaching sustained ROSC. Multivariate analysis showed that long CPR duration, hematology/oncology patients, and pre-arrest vasoactive drug infusion were significantly associated with decreased hospital survival (p<0.05).

CONCLUSIONS

Outcomes of CPR for pediatric patients with IHCA in Taiwan were comparable to corresponding reports in Western countries, but more hematology/oncology patients were included. Long CPR duration, hematologic or oncologic underlying diseases, and vasoactive agent infusion prior IHCA were associated with poor outcomes. The concept of palliative care should be proposed to families of terminally ill cancer patients in order to avoid unnecessary patient suffering. Also, establishing a balanced duty system in the future might increase chances of sustained ROSC.

Using demand analysis and system status management for predicting ED attendances and rostering

INTRODUCTION

It has been observed that emergency department (ED) attendances are not random events but rather have definite time patterns and trends that can be observed historically.

OBJECTIVES

To describe the time demand patterns at the ED and apply systems status management to tailor ED manpower demand.

METHODS

Observational study of all patients presenting to the ED at the Singapore General Hospital during a 3-year period was conducted. We also conducted a time series analysis to determine time norms regarding physician activity for various severities of patients.

RESULTS

The yearly ED attendances increased from 113387 (2004) to 120764 (2005) and to 125773 (2006). There was a progressive increase in severity of cases, with priority 1 (most severe) increasing from 6.7% (2004) to 9.1% (2006) and priority 2 from 33.7% (2004) to 35.1% (2006). We noticed a definite time demand pattern, with seasonal peaks in June, weekly peaks on Mondays, and daily peaks at 11 to 12 am. These patterns were consistent during the period of the study. We designed a demand-based rostering tool that matched doctor-unit-hours to patient arrivals and severity. We also noted seasonal peaks corresponding to public holidays.

CONCLUSION

We found definite and consistent patterns of patient demand and designed a rostering tool to match ED manpower demand.

Simulation-Based Education Improves Quality of Care During Cardiac Arrest Team Responses at an Academic Teaching Hospital

BACKGROUND

Simulation technology is widely used in medical education. Linking educational outcomes achieved in a controlled environment to patient care improvement is a constant challenge.

METHODS

This was a retrospective case-control study of cardiac arrest team responses from January to June 2004 at a university-affiliated internal medicine residency program. Medical records of advanced cardiac life support (ACLS) events were reviewed to assess adherence to ACLS response quality indicators based on American Heart Association (AHA) guidelines. All residents received traditional ACLS education. Second-year residents (simulator-trained group) also attended an educational program featuring the deliberate practice of ACLS scenarios using a human patient simulator. Third-year residents (traditionally trained group) were not trained on the simulator. During the study period, both simulator-trained and traditionally trained residents responded to ACLS events. We evaluated the effects of simulation training on the quality of the ACLS care provided.

RESULTS

Simulator-trained residents showed significantly higher adherence to AHA standards (mean correct responses, 68%; SD, 20%) vs traditionally trained residents (mean correct responses, 44%; SD, 20%; p = 0.001). The odds ratio for an adherent ACLS response was 7.1 (95% confidence interval, 1.8 to 28.6) for simulator-trained residents compared to traditionally trained residents after controlling for patient age, ventilator, and telemetry status.

CONCLUSIONS

A simulation-based educational program significantly improved the quality of care provided by residents during actual ACLS events. There is a growing body of evidence indicating that simulation can be a useful adjunct to traditional methods of procedural training.