In-hospital cardiac arrest: Is outcome related to the time of arrest?

BACKGROUND: Whether outcome from in-hospital cardiopulmonary resuscitation (CPR) is poorer when it occurs during the night remains controversial. This study examined the relationship between CPR during the various hospital shifts and survival to discharge. METHODS: CPR attempts occurring in a tertiary hospital with a dedicated, certified resuscitation team were recorded prospectively (Utstein template guidelines) over 24 months. Medical records and patient characteristics were retrieved from patient admission files. RESULTS: Included were 174 in-hospital cardiac arrests; 43%, 32% and 25% in morning evening and night shifts, respectively. Shift populations were comparable in demographic and treatment related variables. Asystole (p < 0.01) and unwitnessed arrests (p = 0.05) were more common during the night. Survival to discharge was poorer following night shift CPR than following morning and evening shift CPR (p = 0.04). When asystole (being synonymous with death) was excluded from the analysis, the odds of survival to discharge was not higher for witnessed compared to unwitnessed arrest but was 4.9 times higher if the cardiac arrest did not occur during the night shift (p = 0.05, logistic regression). The relative risk of eventual in-hospital death for patients with return of spontaneous circulation (ROSC) following night shift resuscitation was 1.9 that of those with ROSC following morning or evening resuscitation (Cox regression). CONCLUSIONS: Although unwitnessed arrest is more prevalent during night shift, resuscitation during this shift is associated with poorer outcomes independently of witnessed status. Further research is required into the causes for the increased mortality observed after night shift resuscitation.     

A decade of in-hospital resuscitation: Outcomes and prediction of survival?

OBJECTIVE: To provide survival rates and associated factors from a 10-year study of in-hospital cardiopulmonary resuscitation (CPR). DESIGN: Longitudinal prospective case register study of all adult in-hospital CPR attempts conducted from April 1993 to March 2003. SETTING: 1200-bed general hospital in Plymouth (UK). PATIENTS: 2121 adult in-hospital CPR attempts in Derriford Hospital, Plymouth during the period April 1993-March 2003. MAIN OUTCOME MEASURES: Immediate, 24 h, hospital discharge and 12 month survival rates. RESULTS: Following CPR the immediate survival rate (95% confidence interval (C.I.)) was 38.6% (36.5, 40.7), then 24.7% (22.8, 26.6) at 24 h, 15.9% (14.4, 17.6) at discharge and 11.3% (10.0, 12.7) at 12 months. The primary arrhythmia, age, duration of arrest and time of arrest were strongly related to survival at 24 h and discharge. There were very low survival rates for pulse-less electrical activity (PEA) and asystole compared to VT/VF arrests; survival rates were highest for those less than 60 years and decreased with increasing age. The longer the resuscitation the less the survival, and those who arrested at night were less likely to survive. The primary arrest, respiratory or cardiac, was also independently associated with survival at 24 h but not with hospital discharge. Sex and the commencement of basic life support (BLS) within 3 min was not an independent predictor of survival. CONCLUSION: The findings of this study show resuscitation survival rates from a 10-year study and indicate some of the key predictors of survival.     

Long-term prognosis after out-of-hospital cardiac arrest and primary percutaneous coronary intervention

AIMS: To study the long-term survival after out-of-hospital cardiac arrest and successful cardiopulmonary resuscitation (CPR) in patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). MATERIAL AND METHODS: In-hospital and 2-year survival of 40 patients treated with primary PCI after out-of-hospital cardiac arrest and STEMI was compared with that of a reference group of 325 STEMI patients, without cardiac arrest, also treated with primary PCI in the same period. RESULTS: In the group with out-of-hospital cardiac arrest, both in-hospital and 2-year mortality was 27.5%. In the reference group, in-hospital and 2-year mortality was 4.9 and 7.1%, respectively. After discharge from hospital there was no significant difference in mortality between the groups. CONCLUSION: Long-term prognosis is good in selected patients after successful out-of-hospital CPR and STEMI treated with primary PCI.     

The Utstein template and the effect of in-hospital decisions: the impact of do-not-attempt resuscitation status on survival to discharge statistics.

BACKGROUND: Variables for reporting outcome of pre-hospital cardiac arrest have been delineated in the Utstein style template. The primary outcome statistic is survival to hospital discharge (SHD). The template allows comparisons of pre-hospital care systems and has been used to determine the benefit of pre-hospital interventions. Post-resuscitation care has not been standardized and in-hospital events that affect SHD are not considered in the template. STUDY PURPOSE: To determine the frequency and timing with which do-not-attempt resuscitation (DNAR) status is conferred following resuscitation from pre-hospital cardiac arrest and to assess the impact of this action on SHD. METHODS: A 4-year retrospective, observational cohort study of all adult patients successfully resuscitated from nontraumatic pre-hospital cardiac arrest and admitted to a single municipal teaching hospital. Study variables included age, witnessed arrest, bystander cardiopulmonary resuscitation (CPR), initial rhythm documented by paramedics, hospital admission rate, frequency and time at which DNAR status was conferred, and SHD. RESULTS: Four hundred and eighteen adult patients experienced pre-hospital arrest and received standard advanced cardiac life support interventions during the study period. Seventy-nine patients (19%; 95% confidence interval (CI), 15-23%) survived to be admitted to the hospital. Fifty-four of these patients (68%; 96% CI, 57-78%) were subsequently placed in DNAR status. Only one of these patients had a living will or advanced directive prior to cardiopulmonary arrest. In 37 DNAR patients (68%; 95% CI, 54-81%), DNAR status was conferred within 24 h of hospital admission. For patients made DNAR within 24 h of admission, 38% had a witnessed arrest, 22% had ventricular fibrillation as the first documented arrest rhythm, and 29% received bystander CPR. When patients made DNAR are included in the calculation of SHD rate, the SHD rate for the study period was 5.3% (95% CI, 3.3-7.8%). If DNAR patients are excluded, the SHD was 6.1% (95% CI, 3.8-9.0%), representing a 15% increase in SHD rate. CONCLUSION: In-hospital care and medical decision making are not considered in the Utstein template and can have a significant effect on reported survival statistics. When assessing the benefit of pre-hospital interventions, it may be preferable to consider survival to hospital admission as the primary outcome statistic until such time as post-resuscitation care after hospital admission is rigidly standardized.     

Characteristics and outcome of cardiorespiratory arrest in children

OBJECTIVE: To analyse the present day characteristics and outcome of cardio-respiratory arrest in children in Spain. DESIGN: An 18-month prospective, multicentre study analysing out-of-hospital and in-hospital cardio-respiratory arrest in children. Patients and methods: Two hundred and eighty-three children between 7 days and 17 years of age with cardio-respiratory arrest. Data were recorded according to the Utstein style. The outcome variables were the sustained return of spontaneous circulation (initial survival), and survival at 1 year (final survival). Three hundred and eleven cardio-respiratory arrest episodes, composed of 70 respiratory arrests and 241 cardiac arrests in 283 children were studied. Accidents were the most frequent cause of out-of-hospital arrest (40%), and cardiac disease was the leading cause (31%) of in-hospital arrest. Initial survival was 60.2% and 1 year survival was 33.2%. The final survival was higher in patients with respiratory arrest (70%) than in patients with cardiac arrest (21.1%) (P <0.0001). Although many individual factors correlated with mortality, multivariate logistic regression revealed that the best indicator of mortality was a duration of cardiopulmonary resuscitation of over 20 min (odds ratio: 10.35; 95% CI 4.59-23.32). CONCLUSIONS: In Spain, the present mortality from cardio-respiratory arrest in children remains high. Survival after respiratory arrest is significantly higher than after cardiac arrest. The duration of cardiopulmonary resuscitation attempt is the best indicator of mortality of cardio-respiratory arrest in children.     

The epidemiology and resuscitation effects of cardiopulmonary arrest among hospitalized children and adolescents in Beijing: An observational study

Aim

To investigate the epidemiology and resuscitation effects of cardiopulmonary arrest among hospitalized children and adolescents in Beijing.

Methods

A prospective multicentre study was conducted in four hospitals in urban/suburban areas of Beijing. Patients aged 1 month–18 years with cardiopulmonary arrest and received cardiopulmonary resuscitation (CPR) who were consecutively hospitalised during the study period (1 September 2008–31 December 2010) were enrolled. Data was collected and analyzed using the “in-hospital Utstein style”. Neurological outcome was assessed with the pediatric cerebral performance category (PCPC) among patients who survived.

Result

201 of 108,673 hospitalized patients (0.18%) had cardiopulmonary arrest during their hospitalization. Of these, 174 patients underwent CPR. The most common causes of cardiopulmonary arrest were the diseases of respiratory system (29.3%) and circulatory system (19.0%). The most common initial rhythm was bradycardia (72.4%). About 108 patients (62.1%) had restoration of spontaneous circulation (ROSC). Forty-nine patients (28.2%) survived to hospital discharge, 25 (14.5%) survived 6 months post discharge, and 21 (12.1%) survived 1 year post discharge. Out of the 21 patients who survived 1 year after hospital discharge, 18 had good neurological outcome. Multivariate logistic regression analysis showed age, duration of CPR and endotracheal intubation performed before cardiopulmonary arrest were independent factors of cardiopulmonary resuscitation effect.

Conclusion

The prevalence of in-hospital cardiopulmonary arrest in children and adolescents is low. The long-term result of children and adolescents survived from cardiopulmonary resuscitation is quite good. Age, CPR duration and endotracheal intubation performed before cardiopulmonary arrest were independent factors of cardiopulmonary resuscitation effect.     

Characteristics and outcome among patients suffering from in hospital cardiac arrest in relation to the interval between collapse and start of CPR

AIM: To describe survival after in-hospital cardiac arrest in relation to the interval between collapse and start of cardiopulmonary resuscitation (CPR). PATIENTS: All patients suffering in-hospital cardiac arrest in Sahlgrenska University Hospital in G?teborg, Sweden between 1994 and 1999 in whom resuscitative efforts were attempted and for whom the interval between collapse and start of CPR was known. METHODS: Prospective recording of various factors at resuscitation including the interval between collapse and start of CPR. Retrospective evaluation via medical records of patients' previous history, clinical situation prior to cardiac arrest and final outcome. RESULTS: Survival to discharge was 33% among the 344 patients in whom CPR was started within the first minute as compared with 14% among the 88 patients in whom CPR started more than 1 min after collapse (P=0.008). The corresponding figures for patients found in ventricular fibrillation was 50 versus 32% (NS); for patients found in pulseless electrical activity 9 versus 3% (NS) and for patients found in asystole 19 versus 0% (NS). Correcting for dissimililarties in the previous history and factors at resuscitation, the adjusted odds ratio and 95% confidence limits for being discharged from hospital when CPR was started within 1 min compared with a later start was 3.06 with 95% confidence limits of 1.59-6.31. CONCLUSION: Among patients with in-hospital cardiac arrest in whom the interval between collapse and start of CPR was known, we found that in 80% of the cases CPR was started within the first minute after collapse. Among these patients, survival to discharge was twice that of patients in whom CPR was started later. These results highlight the importance of immediate CPR after in-hospital cardiac arrest.     

Assessment of in-hospital cardiopulmonary resuscitation using Utstein template in a university hospital

The aim of this study was to evaluate the effectiveness of in-hospital cardiopulmonary resuscitation (CPR) strategies and identify key predictors of post-CPR survival in a university hospital setting. Using a form recommended by the European Resuscitation Council, data regarding in-hospital CPR attempts from January 2001 to December 2002 were recorded and analyzed. The main outcomes of interest were immediate survival after CPR and survival to hospital discharge. Of 307 patients who suffered cardiac arrest in the study period, 103 (33.5%) were resuscitated. Of these 103 patients, 28 (27.2%) survived immediately and 12 (11.7%) survived to hospital discharge. The key predictors of immediate survival were CPR duration and initial cardiac rhythm as monitored by ventricular fibrillation/pulseless ventricular tachycardia (VF/VT). The key predictors of survival to hospital discharge were CPR duration, immediate defibrillation, Glasgow Coma Scale score, and Early Prediction Score. Together, our results suggest that in-hospital CPR strategies require improvement. They also underscore the importance of data collection and analysis in evaluating the effectiveness of inhospital CPR strategies.     

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

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.     

An outcome study of out-of-hospital cardiac arrest using the Utstein template--a Japanese experience

Publication of the Utstein style template has made it possible to evaluate and compare national, regional, and hospital based Emergency Medical Services. This research was a national investigation to present outcome data for out-of-hospital cardiac arrest (OHCA) patients in Japan. 3029 OHCA patients who were transported to 10 Emergency and Critical Care Medical Center from November 1997 to April 1999 were recorded according to the Utstein style and the outcome evaluated by logistic regression analysis. Among 3029 OHCA patients, 109 were found dead. The remaining 2920 patients who underwent cardiopulmonary resuscitation (CPR) by emergency medical technicians (EMT) were included in this study. Among these patients, 1294 were considered of primary cardiac origin patients by the EMT and 722 of these patients suffered a witnessed cardiac arrest. Bystander CPR were performed in 28.4% of these witnessed patients and the discharge rate was 3.5% overall and 11.4% in witnessed VF/VT. Outcome analysis showed that a discharge rate in witnessed primary cardiac arrest was 30% in prehospital resuscitation which was 7.5 times higher than in-hospital emergency room resuscitation groups (4.0%). The longer the interval between an emergency telephone call and defibrillation, the lower the 1 month survival rate, which reached almost 0% at 30 min. Follow up evaluation after discharge revealed that the survival rate rapidly decreased from 24 h to 3 months, then became a plateau in primary cardiac patients was rapidly decreased from 24 h to 1 month, then became a near plateau in non-cardiac origin group. To improve the resuscitation rate in the prehospital phase, a prehospital medical control system should be developed with expansion of on scene techniques by Japanese paramedics such as tracheal intubation, administration of emergency drugs and early defibrillation with standing orders. Education and motivation of first responders will be needed and every effort should be concentrated on improving bystander CPR rate.     

Cardiopulmonary resuscitation in a pediatric ICU

A 30-month, retrospective study of CPR was undertaken in a 10-bed, medical/surgical pediatric ICU (PICU). The 121 episodes of CPR reviewed represented 81 of 1357 admissions and 7537 cumulative days of PICU care. Of the 121 CPR attempts, 64% were initially successful, 48% were associated with at least 24-h survival, and 31% were followed by discharge from PICU. Unlike pediatric arrests outside the hospital or on general pediatric wards, PICU arrests were seldom unanticipated, were commonly nonrespiratory in origin, and generally occurred in spite of aggressive support. Of 118 PICU deaths during the study period, 45 (38%) were associated with CPR. In the 73 remaining PICU deaths, CPR had been withheld because of an order not to resuscitate. CNS status before arrest was the most important factor influencing outcome. In this pediatric population, 29% were noncomatose survivors 24 h after more than 30 min of resuscitation.     

Cardiopulmonary resuscitation in critically ill neurologic-neurosurgical patients

OBJECTIVES: To establish the rate of successful cardiopulmonary resuscitation (CPR) and to study outcome predictors in patients who experienced in-hospital cardiac arrest after being admitted to the neurologic-neurosurgical intensive care unit (ICU) with a primary neurologic diagnosis. PATIENTS AND METHODS: We identified patients admitted to the neurologic-neurosurgical ICU between 1994 and 2001 who experienced in-hospital cardiac arrest and received CPR. Functional outcome was assessed using the modified Rankin scale. RESULTS: During the study period, 38 consecutive patients experienced in-hospital cardiac arrest and received CPR. The median age of the patients was 65 years (range, 16-81 years), and the mean interval from admission to CPR was 12 days (range, 3 hours to 47 days). Acute intracranial disease was present in 32 patients (84%). Twenty-one patients (55%) were in the ICU at the time of the cardiac arrest; cardiac arrests in the wards occurred at a mean interval of 9 days (range, 1-45 days) after ICU discharge. Cardiopulmonary resuscitation achieved return of spontaneous circulation in 23 patients (61%). Seven patients (18%) were discharged from the hospital, 5 of whom later achieved a modified Rankin scale score of 2 or lower. Cardiac arrest after a deteriorating clinical course resulted in uniformly fatal outcomes. Duration of CPR shorter than 5 minutes and CPR in the ICU were associated with survival and good functional recovery. CONCLUSIONS: Cardiopulmonary resuscitation is a worthwhile procedure in severely ill neurologic-neurosurgical patients, regardless of the patient's age. However, the outcome after CPR appears much worse in patients with a prior deteriorating clinical course.     

Pediatric in-intensive-care-unit cardiac arrest: incidence, survival, and predictive factors

OBJECTIVE: To describe the incidence, survival, and neurologic outcome of in-intensive-care-unit (ICU) cardiac arrest and to identify factors predictive of survival to hospital discharge. METHODS: We performed a retrospective cohort study. Eligible patients were <18 yrs of age and experienced a cardiac arrest during their admission to a multidisciplinary pediatric intensive care unit in the 5.5-yr period ending June 2002. Cardiac arrest was defined as the administration of chest compressions or defibrillation for a nonperfusing cardiac rhythm. Mortality and the Paediatric Cerebral Performance Score were measured and presented according to the Utstein style. Factors predictive of survival to hospital discharge were identified by univariate analysis and independent predictors were identified by multivariate analysis. MAIN MEASUREMENTS AND RESULTS: Ninety-one children had cardiac arrest, yielding an incidence of 0.94 cardiac arrests per 100 admissions. Resuscitation was successful in 75 (82%) children, 61 (67%) survived 24 hrs, 25 (27%) children survived to ICU discharge and 23 (25%) to hospital discharge. At hospital discharge, the median Pediatric Cerebral Performance Category score was 2 (range, 1-3) and the median Pediatric Overall Performance Category score was 3 (range, 1-4). No child was assessed as normal on both scores. The independent positive predictors of hospital mortality were the presence of renal failure before cardiac arrest (odds ratio [OR], 6.1; 95% confidence interval [CI], 1.8-31), being on epinephrine infusion at time of cardiac arrest (OR, 9.5; 95% CI, 1.5-62), and the administration of one or more calcium boluses during resuscitation (OR, 5.4; 95% CI, 1.1-25). The use of extracorporeal membrane oxygenation (ECMO) within 24 hrs after cardiac arrest was associated with reduced hospital mortality (OR, 0.18; 95% CI, 0.04-0.76). CONCLUSIONS: In-ICU cardiac arrest is associated with high in-hospital mortality and subsequent morbidity in survivors. Prearrest renal dysfunction and epinephrine infusion were associated with increased in-hospital mortality. The use of post-arrest ECMO within 24 hrs was associated with reduced mortality. Rigorous prospective evaluation of the role of ECMO following cardiac arrest is needed.     

Evaluation of the in-hospital Utstein template in cardiopulmonary resuscitation in secondary hospitals

INTRODUCTION: The in-hospital Utstein template for cardiopulmonary resuscitation (CPR) was assessed in four secondary hospitals (334-441 beds) which did not have systematic data collection. MATERIALS AND METHODS: The reports and outcome over a period of 12 months during the years 2000-2001 were evaluated. RESULTS: Of a total of 1690 patients that had a cardiac arrest (CA), 204 (12%) were resuscitated. Information on the collected Utstein parameters were available as follows: initial rhythm in 91%, time interval from collapse to defibrillation (in case of ventricular fibrillation or ventricular tachycardia as initial rhythm) in 90%, time interval to return of spontaneous circulation (ROSC) in 83% and duration of resuscitation in 83%. ROSC was achieved in 69 patients (34%, CI 27-41%) and 34 (17%, CI 11-23%) survived to hospital discharge. Twenty patients showed satisfactory neurological recovery (10%, CI 6-14%). Eighteen (9%, CI 5-13%) patients were alive at 12 months from the event. Factors associated with survival to hospital discharge were VF/VT (P=0.007) as the initial rhythm and shorter interval to defibrillation (P=0.046). CONCLUSION: The in-hospital Utstein template was logical but laborious and it provided tools for resuscitation management evaluation in the study hospitals. For continuous use, a slightly compressed model may be warranted. In the present material, the overall survival rate to hospital discharge was in line with previous reports but there were somewhat less neurologically satisfactory survivors. There is an evident need to improve the outcome of patients suffering CA on the wards. An important step is to reduce the time interval to defibrillation.     

Early defibrillation and the chain of survival in 'in-hospital' adult cardiac arrest; minutes count

OBJECTIVE: To report the outcomes from and the impact of the chain of survival in 'in-hospital' cardiac arrest where the presenting rhythm was VF/VT, the arrest was witnessed, defibrillation was conducted rapidly and no other resuscitation interventions were required. Outcome measures: Any return of spontaneous circulation and discharge from hospital. METHODS: A 2-year prospective resuscitation audit using the Utstein style was conducted within a major London NHS Hospital Group. RESULTS: There were 124 patients who had primary VF/VT arrest. Eight were excluded from the study and 14 had non-witnessed cardiac arrest. Twenty one patients had witnessed VF/VT arrest but with delayed defibrillation, 81 patients had witnessed VF/VT arrest with rapid defibrillation, 69 patients had witnessed VF/VT arrest with rapid defibrillation, CPR and other additional interventions. There were 15 patients that had witnessed cardiac arrest with a presenting rhythm of VF/VT, who received rapid defibrillation and had no ventilation or chest compression prior to or following defibrillation. All 15 patients achieved a return of spontaneous circulation, and 12 were discharged alive. CONCLUSIONS: Rapid defibrillation prior to any other resuscitation intervention is associated with increased survival from witnessed VF/VT arrest in in-hospital cardiac arrest victims, and that the time to first shock is critical in enhancing the prospects of long-term survival in these patients.     

A prospective study of outcome of in-patient paediatric cardiopulmonary arrest

BACKGROUND: Few prospective studies of the incidence and outcome of paediatric in-hospital cardiopulmonary arrest have been reported to enable quality assurance comparisons within and between institutions. METHODS: All cardiac and respiratory arrests and their management over a 41-month period in children not subject to palliative treatment or to a 'do not resuscitate' order were recorded and analysed using the Utstein template. RESULTS: Cardiac arrest occurred in a total of 111 of 104,780 admissions (1.06/1000) while respiratory arrest alone occurred in 36 (0.34/1000). Return of spontaneous circulation (ROSC) was achieved in 81 patients (73%) in cardiac arrest but only 40 (36%) were discharged from hospital and 38 (34%) survived for 1 year. The 1-year survival from respiratory arrest alone was 97%. Cardiac arrest was four times more common (89 versus 22) and approximately 90 times the incidence in the intensive care unit compared with wards but 1-year survival was similar (34% versus 36%). The initial heart rhythms were hypotensive-bradycardia in 73 (66%) with 38% survival; asystole in 17 (15%) with 12% survival; ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in 10 (9%) with 40% survival; pulseless electrical activity (PEA) in 10 (9%) with 30% survival and SVT in 1 with survival. Secondary ventricular fibrillation occurred in 15 children given adrenaline (epinephrine) for treatment of asystole, hypotensive-bradycardia or PEA of whom 11 had received adrenaline in an initial dose of > 15 mcg/kg and 4 had < 15 mcg/kg (P = 0.0013). Eleven of 15 patients (73%) in secondary VF never achieved ROSC. CONCLUSIONS: In-patient paediatric cardiac arrest has a mediocre outcome with a better outlook if the initial rhythm is hypotensive-bradycardia, VF or pulsatile VT. Doses of adrenaline greater than 15 mcg/kg given for non-shockable rhythms may cause secondary VF which has a worse outcome than primary VF.     

Short-term health system costs of paediatric in-hospital acute life-threatening events including cardiac arrest

ObjectivesAcute life-threatening events in children are medical emergencies requiring immediate intervention. They can be due to cardiac arrest, respiratory arrest or another cause of sudden compromise for example, choking. Internationally, hospital systems are being introduced to reduce preventable acute life-threatening events and, despite having significant resource implications, have not yet been subject to economic analysis. This study presents the additional short-term health service costs of in-hospital acute life-threatening events to inform a cost-effectiveness analysis of prevention strategies.MethodologyPatient level costs (GB pounds, price year 2005), in excess of baseline costs, were collected from a short-term NHS perspective. The cost per survivor to hospital discharge included the cost of the cardiopulmonary resuscitation attempt, resuscitation preparedness, and the cost of in-hospital post-resuscitation care. Acute life-threatening events calls were classified into two groups: cardiac arrest, and respiratory arrest and other acute life threatening events. Outcomes from these groups were compared to a similar group of unplanned Paediatric Intensive Care (PIC) admissions. All survival and length of stay outcomes were calculated for the first episode.ResultsThe survival to hospital discharge was 64.4% (65/101), (95% Confidence Intervals 55.02, 73.70) for all acute life-threatening event calls, and 41.3% (12/29), (95% Confidence Intervals 23.45, 59.31) for cardiac arrest. The mean cost of the resuscitation attempt was £3664 for all acute life-threatening event calls, and £3884 for cardiac arrest. The annual cost of cardiopulmonary resuscitation preparedness was £181,565.The mean cost of the post-event length of stay in hospital was £22,562 for cardiac arrest, £26,335 for other acute life-threatening events, and £26,138 for urgent PIC admissions. The cost per survivor to hospital discharge was £53,289.ConclusionThe short-term costs of paediatric in-hospital acute life-threatening events, including cardiac arrest, from an NHS perspective, are more expensive than those reported for adults, but similar to other life saving treatments. This new information will serve to improve efficiency in the current resuscitation programme and contribute to cost-effectiveness analysis of prevention strategies.     

A predictive model for survival after in-hospital cardiopulmonary arrest

BACKGROUND: In-hospital cardiopulmonary resuscitation (CPR) has seen a steady increase in the application of technology and techniques since the introduction of closed cardiac massage in 1960. Despite this progress, there has not been a demonstrated improvement in survival rates after in-hospital cardiac arrest over the last 40 years. Identification of prognostic factors associated with survival after a resuscitation attempt can help physician decisions and patients' end-of-life choices in a pre-arrest situation. METHODS: Using an Utstein-based template we analyzed 219 consecutive adult attempted resuscitations in a large urban teaching hospital over a 3-year period. The main outcome measures were survival to discharge, 1 and 3 months. Backwards stepwise logistic regression was used to select baseline variables that predict survival at discharge, 1 and 3 months. RESULTS: Survival rates at discharge, 1 and 3 months were 15.1, 13.3, and 11.5%. Meaningful neurological status (cerebral performance score of 1) at discharge was achieved in 61% of survivors. Independent predictors of survival were: higher body-mass index (BMI), presence of chronic renal insufficiency (CRI), respiratory arrest, ventricular tachycardia/fibrillation (VT/VF) as initial rhythm and arrest early during the hospital stay. A risk model based on these variables demonstrated a significant fit between predicted and observed survival at discharge with goodness of fit test P-value of 0.87. CONCLUSIONS: Survival after in-hospital cardiopulmonary arrest is poor and can be estimated by using clinical variables. If validated in a large prospective trial, this score could help physicians in attempting resuscitation, patients and families in making end-of-life decisions and hospitals in resource allocation.