Elsevier

Resuscitation

Volume 62, Issue 3, September 2004, Pages 291-297
Resuscitation

In-hospital cardiac arrest: survival depends mainly on the effectiveness of the emergency response

https://doi.org/10.1016/j.resuscitation.2004.03.020Get rights and content

Abstract

Objectives: To evaluate the factors affecting the outcome of in-hospital cardiac arrest. Setting: A 1400-bed tertiary care teaching hospital with a dedicated cardiac arrest team (CAT). The CAT was immediately available in monitored areas (intensive care unit and emergency room). In the wards the staff had only BLS skills and automated external defibrillation was not available. Methods: A 2-year prospective audit according to the Utstein style. Results: A total of 114 cardiac arrests (37 with VF/VT and 77 with non-VF/VT) were included. Fifty-two cardiac arrests (46%) occurred in monitored areas, 62 (54%) occurred in non-monitored areas. The CAT arrival time in non-monitored areas was 3.98±1.73 min. Thirty-seven patients (32%) survived to hospital discharge. Cardiac arrests occurring in monitored areas had a significantly better outcome than those occurring in the wards. Patient survival in the wards was significantly higher when the CAT arrival time was less than 3 min. No patient whose CAT arrival time was longer than 6 min survived. CAT arrival time was significantly shorter (1.30±1.70) in survivors than in non-survivors (2.51±2.37; P<0.005). Sex, age and presence of bystanders were not significantly associated with survival. Conclusions: In our setting, where bystander defibrillation was not available, the survival of patients having cardiac arrest in non-monitored areas strongly depends on advanced life support provided by the CAT. A faster CAT response and early defibrillation from the ward staff are the most important improvements necessary to increase cardiac arrest survival in our setting.

Sumàrio

Objectivos: Avaliar os factores que afectam o resultado na paragem cardı́aca intra-hospitalar. Ambiente: Um hospital terciário com ensino, de 1400 camas, com uma equipa dedicada de resposta a paragem cardı́aca (CAT). A CAT estava imediatamente disponı́vel nas áreas monitorizadas (unidade de cuidados intensivos e sala de emergência). Os profissionais da enfermarias tinham apenas competência em suporte básico de vida e a desfibrilhação automática externa não estava disponı́vel. Métodos: Uma auditoria prospectiva de 2 anos, de acordo com o método de Utstein. Resultados: Foi incluı́do um total de 114 paragens cardı́acas (37 com FV/TV e 77 com ritmos não-FV/TV). Cinquenta e duas paragens cardı́acas (46%) ocorreram em áreas monitorizadas, 62 (54%) ocorreram em áreas não monitorizadas. O tempo de chegada da CAT ás áreas não monitorizadas foi de 3.98 ± 1.73 min. Sobreviveram até á alta hospitalar 37 doentes (32%). As paragens que ocorreram em áreas monitorizadas tiveram um resultado significativamente melhor que as que aconteceram nas enfermarias. A sobrevida nas enfermarias foi significativamente mais alta quando a CAT chegava em menos de 3 min. Nenhum doente em que o tempo de chegada da CAT foi superior a 6 min sobreviveu. O tempo de chegada da CAT foi significativamente mais curto (1.30 ± 1.70) nos sobreviventes que nos não sobreviventes (2.51 ± 2.37; P < 0.005). O sexo, idade e a presença de testemunhas não estavam significativamente associados a sobrevida. Conclusões: No nosso contexto, onde a desfibrilhação por testemunhas da paragem não estava disponı́vel, a sobrevivência de doentes que sofrem paragem cardı́aca em áreas não monitorizadas depende fortemente de suporte avançado de vida realizado por CATs. Uma resposta mais rápida da CAT e a desfibrilhação precoce pelo pessoal da enfermaria são as melhorias mais importantes necessárias para aumentar a sobrevivência das paragens cardı́acas no nosso contexto.

Resumen

Objetivos: Evaluar los factores que afectan el resultado del paro cardiaco intrahospitalario. Ambiente: Un hospital de cuidados terciarios con 1400 camas con un equipo dedicado al paro cardiaco (CAT). El CAT está inmediatamente disponible en áreas monitorizadas (unidades de cuidados intensivos y sala de emergencias). El personal de las salas solo tienen destrezas de soporte vital básico (BLS) y no se disponı́a de desfibrilación automática externa. Métodos: auditorı́a prospectiva de 2 años de acuerdo al estilo de Utstein. Resultados: Se incluyeron un total de 114 paros cardiacos (37 con VF /VT y 77 con ritmos no VF/VT). Cincuenta y dos paros cardiacos (46%) ocurrieron en áreas monitorizadas, 62 (54%) ocurrieron en áreas no monitorizadas. El tiempo de arribo del CAT en áreas no monitorizadas fue de 3.98 ± 1.73. Treinta y siete pacientes (32%) sobrevivieron al alta. Los paros cardiacos que ocurrieron en áreas monitorizadas tuvieron resultados significativamente mejores que aquellos que ocurrieron en las salas. La sobrevida de los pacientes de sala fue significativamente mas alta cuando la llegada del CAT fue de menos de 3 minutos. Ningún paciente en quien el tiempo de llegada de CAT fue mayor de 6 minutos sobrevivió. El tiempo de llegada de CAT fue significativamente mas corto (1.30 ± 1.70) en los sobrevivientes que en los no sobrevivientes (2.51 ± 2.37; P < 0.005). El sexo, edad y la presencia de testigos no se asoció significativamente con la sobrevida. Conclusiones: En nuestro ambiente, donde la desfibrilación por testigos no estaba disponible, la sobrevida de pacientes en paro cardı́aco en áreas no monitorizadas depende fuertemente del soporte vital avanzado proporcionado por el CAT. Una respuesta CAT mas rápida y mas importantes necesarios para mejorar la sobrevida del paro cardiaco en nuestro ambiente.

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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