In-hospital cardiac arrest—An Utstein style report of seven years experience from the Sahlgrenska University Hospital

doi:10.1016/j.resuscitation.2005.07.011

Resuscitation

Volume 68, Issue 3, March 2006, Pages 351-358

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Summary

Background

In-hospital cardiac arrest is one of the most stressful situations in modern medicine. Since 1997, there has been a uniform way of reporting – the Utstein guidelines for in-hospital cardiac arrest reporting.

Material and methods

We have studied all consecutive cardiac arrest in the Sahlgrenska University Hospital (SU) between 1994 and 2001 for who the rescue team was alerted in all 833 patients. The primary endpoint for this study was survival to discharge.

Results

Thirty-seven percent survived to hospital discharge. Among patients who were discharged alive, 86% were alive 1 year later. The survivors have a good cerebral outcome (94% among those who were discharged alive had cerebral performance category (CPC) score 1 or 2). The organization at SU is efficient; 80% of the cardiac arrest had CPR within 1 min. Time from cardiac arrest to first defibrillation is a median of 2 min. Almost two-thirds of the patients were admitted for cardiac related diagnoses.

Conclusion

The current study is the largest single-centre study of in hospital cardiac arrest reported according to the Utstein guidelines. We report a high survival for in-hospital cardiac arrest. We have pointed out that a functional chain of survival, short intervals before the start of CPR and defibrillation are probably contributing factors for this.

Introduction

Cardiac arrest in the hospital environment is one of the most stress filled situations in medical practice. Every minute counts. This area of research has had the same problem in reporting as out-of-hospital cardiac arrest. For the latter, there has been a uniform way of reporting since 1990 – the Utstein guidelines. The advantages of a uniform nomenclature are obvious and the in-hospital Utstein guidelines were created in 1997.¹ Since then several studies have been published,2, 3, 4, 5, 6, 7, 8 although some were based on small numbers2, 7 or only patients found in ventricular tachycardia or ventricular fibrillation (VT/VF).⁶ The field is in need of more research to clarify epidemiology, outcome and factors associated with survival. Therefore, have we conducted this study of all consecutive in-hospital cardiac arrests for whom resuscitation was started in Sahlgrenska University Hospital (SU), situated in Gothenburg, Sweden between 1 November 1994 and 31 December 2001.

The aim of the study is to describe the outcome of patients suffering in-hospital cardiac arrest according to the Utstein style. We have previously reported from this registry at an earlier stage but not in the Utstein style of reporting.9, 10, 11, 12

Section snippets

Methods – general

We have collected the data in a prospective way, recording various factors at resuscitation including the time when the CPR team was alerted. We then conducted a retrospective evaluation of the medical records of patients’ previous history and final outcome.

Template

We report an overall survival to discharge of 34% (310/910) of the arrests. There were 833 patients who in all had 910 cardiac arrests. Out of the 833 patients, 310 survived to discharge, a survival rate of 37% (310/833). Out of the 523 patients who died, 435 (83%) died within 24 h after collapse. See Template 1.

Cerebral performance category (CPC) score (Figure 1)

The CPC scores prior to the cardiac arrest for the whole group (N = 833) was as follows: 87% had CPC score of 1, 7% has CPC score 2. Corresponding figures for survivors are shown in Figure

General results – template

Ventricular fibrillation or tachycardia was recorded as the initial rhythm in almost 49% of the arrests. This is a high figure in comparison with other reported VT/VF rates. Previous Utstein-reports have found VT/VF to occur in between 8 and 33%.2, 3, 4, 5, 6, 7, 8 We do not know why the rate VT/VF is higher in Sahlgrenska, however, we can conclude that the intervals from collapse to defibrillation are comparable with others.⁵ A possible reason can be a functional DNAR policy, and it is

Conclusion

This single-centre study is by far the largest Utstein style report for cardiac arrest in hospital. The overall survival rate for in-hospital cardiac arrest among patients for whom the resuscitation team was called was 37%. This rate of survival is very high in comparison with other Utstein reports of in hospital cardiac arrest ranging from 8 to 26%.2, 3, 4, 8, 15 A combination of factors can contribute to this, including the high percentage of patients found in VT/VF, a functional DNAR policy,

Acknowledgements

This study was made possible by grants from the Swedish Heart and Lung Foundation and Göteborgs Läkaresällskap.

References (21)

R.O. Cummins et al.
Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital “Utstein-style”
Resuscitation
(1997)
C.H. Huang et al.
Factors influencing the outcomes after in-hospital resuscitation in Taiwan
Resuscitation
(2002)
M.A. Peberdy et al.
Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation
Resuscitation
(2003)
K.G. Spearpoint et al.
Early defibrillation and the chain of survival in ’in-hospital’ adult cardiac arrest; minutes count
Resuscitation
(2000)
M.B. Skrifvars et al.
Evaluation of the in-hospital Utstein template in cardiopulmonary resuscitation in secondary hospitals
Resuscitation
(2003)
J. Herlitz et al.
Characteristics and outcome among patients suffering in-hospital cardiac arrest in monitored and non-monitored areas
Resuscitation
(2001)
J. Herlitz et al.
Is there a difference between women and men in characteristics and outcome after in hospital cardiac arrest?
Resuscitation
(2001)
J. Herlitz et al.
Characteristics and outcome among patients suffering from in hospital cardiac arrest in relation to the interval between collapse and start of CPR
Resuscitation
(2002)
J. Herlitz et al.
Characteristics and outcome among patients suffering from in hospital cardiac arrest in relation to whether the arrest took place during office hours
Resuscitation
(2002)
J.T. Niemann et al.
The Utstein template and the effect of in-hospital decisions: the impact of do-not-attempt resuscitation status on survival to discharge statistics
Resuscitation
(2001)

There are more references available in the full text version of this article.

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In-hospital cardiac arrest: incidence, prognostic factors and results
2023, Revista Espanola de Anestesiologia y Reanimacion
La parada cardiorrespiratoria (PCR) intrahospitalaria es una entidad clínica con elevada morbimortalidad que presentan hasta el 2% de los pacientes ingresados. La PCR supone un importante problema de salud pública a nivel económico, social y sanitario, susceptible de revisión y mejora. El objetivo de este estudio es determinar su incidencia, la recuperación de la circulación espontánea (RCE) y la supervivencia en el Hospital de la Princesa, así como las características clínicas y demográficas de los pacientes que la sufren.
Estudio observacional, retrospectivo, descriptivo, de tipo registro de casos, durante un periodo de 12 meses, de pacientes por los que se avisó por PCR al equipo de intervención rápida (EIR) compuesto por el servicio de Anestesiología y Reanimación.
Un total de 44 pacientes fueron incluidos en el estudio, de los cuales 22 (50%) eran mujeres. La edad media fue de 75,70 años (± 15,78 años). La incidencia obtenida fue de 2,88 PCR por cada 100.000 ingresos hospitalarios; 22 (50%) pacientes consiguieron la RCE y 11 (25%) obtuvieron la supervivencia al alta hospitalaria. La comorbilidad más prevalente en los pacientes con PCR fue la hipertensión arterial (63,64%). No fueron presenciadas el 66,7% de las PCR y solo el 15,9% presentaron un ritmo desfibrilable.
Los resultados obtenidos son similares a los presentados en otros grandes estudios. Por esta razón, recomendamos implementar EIR y dedicar tiempo a la formación del personal hospitalario en torno a la PCR.
In-hospital cardiac arrest (CA) is a clinical entity with high morbidity and mortality that occurs in up to 2% of hospitalized patients. It is a public health problem with important economic, social, and medical repercussions, and as such its incidence needs to be reviewed and improved. The aim of this study was to determine the incidence of in-hospital CA, return of spontaneous circulation (ROSC), and survival rates at Hospital de la Princesa, and to define the clinical and demographic characteristics of patients with in-hospital CA.
Retrospective observational chart review of patients presenting in-hospital CA and treated by anaesthesiologists from the hospital's rapid intervention team. Data were collected over 1 year.
Forty-four patients were included in the study, of which 22 (50%) were women. Mean age was 75.70 years (± 15.78 years), and incidence of in-hospital CA was 2.88 per 100,000 hospital admissions. Twenty-two patients (50%) achieved ROSC and 11 patients (25%) survived until discharge home. The most prevalent comorbidity was arterial hypertension (63.64%); 66.7% of cases were not witnessed, and only 15.9% presented a shockable rhythm.
These results are similar to those reported in other larger studies. We recommend introducing immediate intervention teams and devoting time to training hospital staff in in-hospital CA.
Survival and functional outcome at hospital discharge following in-hospital cardiac arrest (IHCA): A prospective multicentre observational study
2020, Resuscitation
To evaluate the functional outcome of patients after in-hospital cardiac arrest (IHCA) and to identify associations with good functional outcome at hospital discharge.
Emergency calls were prospectively screened and data collected for IHCAs in seven Australian hospitals. Patients were included if aged > 18 years, admitted as an acute care hospital in-patient and experienced IHCA; defined by a period of unresponsiveness with no observed respiratory effort and commencement of external cardiac compressions. Data collected included patient demographics, clinical and cardiac arrest characteristics, survival and functional outcome at hospital discharge using the modified Rankin Scale (mRS) and Katz Index of Independence in ADLs (Katz-ADL).
152 patients suffered 159 IHCAs (male 66.4%; mean age 70.2 (± 13.9) years). Sixty patients (39.5%) survived, of whom 43 (71.7%) had a good functional outcome (mRS ≤ 3) and 38 (63.3%) were independent with activities of daily living (ADLs) at hospital discharge (Katz-ADL = 6). Younger age (OR 0.95; 95% CI 0.91−0.98; p = 0.003), shorter duration of CPR (OR 0.84; 95% CI 0.77−0.91; p < 0.0001) and shorter duration of hospital admission prior to IHCA (OR 0.96; 95% CI 0.93−0.998; p = 0.04) were independently associated with a good functional outcome at hospital discharge.
The majority of survivors had a good functional outcome and were independent with their ADLs at hospital discharge. Factors associated with good functional outcome at hospital discharge were identified.
One-year survival after in-hospital cardiac arrest: A systematic review and meta-analysis
2018, Resuscitation
Citation Excerpt :
The parallel exclusion of studies based on title and abstract resulted in 239 full text articles eligible for detailed assessment. Finally, we included 39 studies in our systematic review and meta-analysis [15–54]. Full details of study selection are summarized in Fig. 1.
In-hospital cardiac arrest is a major adverse event with an incidence of 1–6/1000 admissions. It has been poorly researched and data on survival is limited. The outcome of interest in IHCA research is predominantly survival to discharge, however recent guidelines warrant for more long-term outcomes. In this systematic review we sought to quantitatively summarize one-year survival after in-hospital cardiac arrest.
For this systematic review and meta-analysis we performed a systematic search of all published data on one-year survival after IHCA up to March 9th, 2018. Results of the meta-analyses are presented as pooled proportions with corresponding 95% prediction intervals (95%PI). Between-study heterogeneity was assessed using I² statistic and the DerSimonian–Laird estimator for τ². Subgroup analyses were performed for cardiac and non-cardiac patients.
We included 40 studies in our systematic review and meta-analysis. The pooled one-year survival after in-hospital cardiac arrest was 13.4% (95%PI: 5.6–28.8%, I² = 100%). Subgroup analysis of cardiac patients revealed a one-year survival of 39.3% (16.1%–68.6%) in patients with a non-cardiac admission characteristic one-year survival was 10.7% (4.4%–23.6%). These data cover the period 1985–2018 and show a modest change in survival over that period (10-year OR: 1.70, 95% CI: 1.04–2.76).
One-year survival after in-hospital cardiac arrest is poor. Survival is higher in patients admitted to cardiac wards. The time trend between 1985–2018 has shown a modest improvement in one-year survival rates. Research into IHCA population characteristics might elicit the issue of heterogeneity and stagnated survival over the past decades.
Outcomes and healthcare-associated costs one year after intensive care-treated cardiac arrest
2018, Resuscitation
Citation Excerpt :
Irrespective of the CA location and the initial cardiac rhythm, the majority of one-year survivors achieved favourable neurological outcome. Previous studies have reported one-year survival rates for hospital-treated OHCA between 27% and 55%, and for IHCA between 6% and 30% [17–23]. Over 80% of hospital survivors had favourable neurological outcome [24–30].
Despite the significant socioeconomic burden associated with cardiac arrest (CA), data on CA patients’ long-term outcome and healthcare-associated costs are limited. The aim of this study was to determine one-year survival, neurological outcome and healthcare-associated costs for ICU-treated CA patients.
This is a single-centre retrospective study on adult CA patients treated in Finnish tertiary hospital’s ICUs between 2005 and 2013. Patients’ personal identification number was used to crosslink data between several nationwide databases in order to obtain data on one-year survival, neurological outcome, and healthcare-associated costs. Healthcare-associated costs were calculated for every patient stratified by cardiac arrest location (OHCA = out-of-hospital cardiac arrest, IHCA = all in-hospital cardiac arrest, ICU-CA = in-ICU cardiac arrest) and initial cardiac rhythm. Cost-effectiveness was estimated by dividing total healthcare-associated costs for all patients from the respective group by the number of survivors and survivors with favourable neurological outcome.
The study population included 1,024 ICU-treated CA patients. The sum of costs for all patients was €50,847,540. At one-year after CA, 58% of OHCAs, 44% of IHCAs, and 39% of ICU-CAs were alive. Of one-year survivors 97% of OHCAs, 88% of IHCAs, and 93% of ICU-CAs had favourable neurological outcome. Effective cost per one-year survivor was €76,212 for OHCAs, €144,168 for IHCAs, and €239,468 for ICU-CAs. Effective cost per one-year survivor with favourable neurological outcome was €81,196 for OHCAs, €164,442 for IHCAs, and €257,207 for ICU-CAs.
In-ICU CA patients had the lowest one-year survival with the effective cost per survivor three times higher than for OHCAs.
Midlife risk factor exposure and incidence of cardiac arrest depending on cardiac or non-cardiac origin
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Little is known about midlife risk factors of future cardiac arrest. Our objective was to evaluate cardiovascular risk factors in midlife in relation to the risk of cardiac arrest (CA) of cardiac and non-cardiac origin later in life.
We cross-matched individuals of the population based Malmö Diet and Cancer study (n = 30,447) with the local CA registry of the city of Malmö. Baseline exposures were related to incident CA.
During a mean follow-up of 17.6 ± 4.6 years, 378 CA occurred, of whom 17.2% survived to discharge. Independent midlife risk factors for CA of cardiac origin included coronary artery disease {HR 2.84 (1.86–4.34) (p < 0.001)}, diabetes mellitus {HR 2.37 (1.61–3.51) (p < 0.001)} and smoking {HR 1.95 (1.49–2.55) (p < 0.001)}. Dyslipidemia and history of stroke were also significantly associated with an elevated risk for CA of cardiac origin.
Independent midlife risk factors for CA of non-cardiac origin included obesity (BMI > 30 kg/m²) {HR 2.37 (1.51–3.71) (p < 0.001)}, smoking {HR 2.05 (1.33–3.15) (p < 0.001)} and being on antihypertensive treatment {HR 2.25 (1.46–3.46) (p < 0.001)}.
Apart from smoking, which increases the risk of CA in general, the midlife risk factor pattern differs between CA of cardiac and non-cardiac origin. Whereas CA of cardiac origin is predicted by history of cardiovascular disease, dyslipidemia and diabetes mellitus, the main risk factors for CA of non-cardiac origin are obesity and hypertension. In addition to control of classical cardiovascular risk factors for prevention of CA, our results suggest that prevention of midlife obesity may reduce the risk of CA of non-cardiac origin.
Frequency and survival pattern of in-hospital cardiac arrests: The impacts of etiology and timing
2016, Resuscitation
Define the frequency and survival pattern of cardiac arrests in relation to the hospital day of event and etiology of arrest.
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.
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).
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.

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^☆: A Spanish translated version of the summary of this article appears as Appendix in the online version at 10.1016/j.resuscitation.2005.07.011.

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CLINICAL PAPERIn-hospital cardiac arrest—An Utstein style report of seven years experience from the Sahlgrenska University Hospital☆

Summary

Background

Material and methods

Results

Conclusion

Introduction

Section snippets

Methods – general

Template

Cerebral performance category (CPC) score (Figure 1)

General results – template

Conclusion

Acknowledgements

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

CLINICAL PAPER
In-hospital cardiac arrest—An Utstein style report of seven years experience from the Sahlgrenska University Hospital☆