In-hospital cardiac arrest: survival depends mainly on the effectiveness of the emergency response
Introduction
Despite the development and diffusion of resuscitation protocols, survival following in-hospital cardiac arrest remains poor. The majority of studies report a survival rate to discharge around 15%, not much higher than out-of-hospital cardiac arrest [1], [2], [3], [4], [5], [6]. This disappointing outcome has been attributed to the more critical condition of patients suffering a cardiac arrest in the hospital compared with that of the out-of-hospital patients, who are healthy enough not to require hospital care.
However, survival rates around 40% have been reported in selected hospitals where the organisation of the emergency system is particularly efficient [7], [8], suggesting that, even inside hospital, the speed and effectiveness of the emergency response may affect the outcome of the cardiac arrest.
When cardiac arrest occurs in critical care areas, expert help is immediately available and advanced life support (ALS) is provided by first responders, while in the wards the staff are usually skilled only in basic life support (BLS), so that defibrillation and ALS depend on the arrival of a cardiac arrest team (CAT), activated in an emergency.
The aims of the present study were:
- 1.
to assess the characteristics and outcome from cardiac arrests occurring in our hospital by making an audit based on the Utstein template;
- 2.
to evaluate the factors affecting the outcome, in particular those related to the effectiveness of the intra-hospital response to cardiac arrest.
Section snippets
Setting
Policlinico Gemelli is a 1400-bed tertiary care teaching hospital that includes all the specialities. The hospital is located in an 11-storey building. The CAT is located in the emergency department (ED), which includes an 18-bed intensive care unit (ICU). In the ED all patients are monitored. Nurses and doctors are ALS trained, so that in case of cardiac arrest the ALS team is activated in few seconds.
All cardiac arrests occurring outside the ED are treated by the CAT, except for the operating
Incidence and general results
During the 2 years of study, 91,515 patients were admitted to the hospital (excluding those admitted to the Paediatric and the Cardiovascular Department), staying a total of 866,780 patient-days. During the same period, 2222 patients died, yielding a mortality rate of 24.6 per 1000 admissions.
A total of 114 patients (71 male, 43 female, age 65.7±16.7 years, median 71 years) were included during the study period. The total incidence of cardiac arrest managed by the CAT was 1.25 per 1000 patient
Discussion
The hospital has been defined as “a self-contained EMS system” [7], where the same model of the “chain of survival”, valid for out-of-hospital cardiac arrest, is applicable. In our hospital the nurses are not allowed to defibrillate and they perform only basic life support (BLS). Thus, defibrillation and advanced life support depend on the arrival of the cardiac arrest team.
In our hospital the wards are distributed on 11 storeys, and the CAT takes the ALS equipment on a emergency cart that
Conclusions
Time to ALS was the most important factor affecting patient survival in our population. This is not surprising, considering the organisation of the emergency response in our hospital. Since in non-monitored wards there are no defibrillators and personnel are not ALS-trained, both defibrillation and advanced life support depend on the arrival of the cardiac arrest team. A faster and more efficient response to cardiac arrest could be achieved by accelerating the CAT arrival and by providing early
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