In-hospital cardiac arrest: Impact of monitoring and witnessed event on patient survival and neurologic status at hospital discharge

doi:10.1016/j.resuscitation.2011.02.028

Resuscitation

Volume 82, Issue 7, July 2011, Pages 845-852

https://doi.org/10.1016/j.resuscitation.2011.02.028 Get rights and content

Abstract

Context

In-hospital cardiac arrest is a significant public health problem with a low probability of patient survival to hospital discharge.

Objective

We evaluated the survival rates for adults with in-hospital cardiac arrest based on whether the arrest was witnessed and/or monitored. Our hypothesis is that patients with either a witnessed or monitored arrest had improved survival to hospital discharge with intact neurologic function.

Design, setting, and patients

We studied a cohort study of 74,213 patients who suffered in-hospital cardiac arrest from January 1, 2000 through February 1, 2008 at the 369 hospitals participating in the National Registry of Cardiopulmonary Resuscitation.

Interventions

The primary exposure of interest was whether the arrest was witnessed and/or monitored (i.e. electrocardiography, pulse oximetry, apnea, or bradycardia monitoring) at the time of arrest. Events were classified as being both monitored and witnessed, monitored only, witnessed only, or neither witnessed nor monitored.

Main outcome measures

Survival to hospital discharge and cerebral performance category at time of discharge.

Results

A total of 73% of patients suffering in-hospital cardiac arrest were witnessed and monitored; 10% were monitored but not witnessed; 9% were witnessed but not monitored; and 8% were neither witnessed nor monitored. Compared with those who were unmonitored/unwitnessed, each of the three groups of patients who were monitored and/or witnessed were over twice as likely to survive to hospital discharge with a cerebral performance category of 1 or 2 (monitored/witnessed OR = 2.40, 95% CI: 2.08, 2.76; monitored-only OR = 2.12, 95% CI: 1.81, 2.47; witnessed-only OR = 2.43, 95% CI: 2.10, 2.83).

Conclusions

Patients who are witnessed and/or monitored at the time of cardiac arrest demonstrate a significantly higher rate of survival to hospital discharge compared to those patients who are neither monitored nor witnessed. Monitored and/or witnessed cardiac arrest patients were also more likely to be discharged with favorable neurologic outcome. Cardiac monitoring confers no additional outcome benefit over direct observation of patients suffering in-hospital cardiac arrest.

Introduction

In-hospital cardiac arrest is a significant health problem with a low probability of patient survival. Survival is influenced by a number of features common to both in-hospital and out-of-hospital arrest, such as time to initiation of chest compression, first defibrillation, initial rhythm, and post-arrest care.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 One of the most important determinants of outcome is time to recognition of the cardiac arrest.3, 4, 5, 7, 8, 9, 10, 12, 13, 14, 15

Electronic monitoring for critically ill, in-hospital patients is commonplace; yet only a small percentage of patients are monitored outside of the intensive care unit (ICU) setting. Because of the low event rate for indiscriminate patient monitoring, the cost and impact on ultimate patient outcome when monitoring is used too liberally has been called into question.¹⁸ Even though the benefit of liberal monitoring has been questioned, the marginal benefit of monitoring over witnessing a patient at the onset of arrest has not been evaluated.9, 10, 12, 13, 14, 15

In order to assess the impact of cardiac monitoring and witnessing the arrest on patient outcome, we evaluated the survival rates for adults suffering in-hospital cardiac arrest based on whether the arrest was witnessed and/or monitored. We hypothesized that both survival and neurologic function would be improved for those patients who were either monitored or witnessed at the time of arrest. Our secondary hypothesis is that monitoring confers no additional benefit over observation alone.

Section snippets

Study data

The American Heart Association (AHA) sponsored National Registry of Cardiopulmonary Resuscitation (NRCPR)¹⁹ – described in detail elsewhere – is comprised of prospective data, collected using Utstein definitions, submitted voluntarily by participating hospitals.20, 21, 22 For the present study, events occurring January 1, 2000 through February 1, 2008 were included. Only index pulseless events (n = 105,679), i.e. the first pulseless event during admission, occurring among patients at least 18

Results

Of the 74,213 cases included in the analysis, 54,341 (73%) were monitored and witnessed, 7322 (10%) were monitored only, 6433 (9%) were witnessed only, and 6177 (8%) were neither witnessed nor monitored.

Patient characteristics are shown in Table 1 by monitored and witnessed status. The majority of monitored/witnessed and monitored-only arrests were equally distributed to cardiac and non-cardiac medical categories (39% each, and 41% and 43%, respectively), while witnessed-only and

Comment

In 1991, the American College of Cardiology (ACC) published a policy statement regarding recommendations for inpatient electrocardiographic monitoring,²³ separating patients into three different risk categories: Class I – High Risk (required monitoring); Class II – Intermediate Risk (may require monitoring); and Class III – Low Risk (likely do not require monitoring). Estrada has investigated the utility and impact of such monitoring among hospitalized patients in two studies24, 25 with only

Conflict of interest statement

No author has a conflict of interest with regards this manuscript.

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Cited by (92)

Understanding the “alarm problem” associated with continuous physiologic monitoring of general care patients
2022, Resuscitation Plus
Citation Excerpt :
Patients who have monitored and/or witnessed arrests are 2.4 times more likely to survive to discharge, although up to 27% of cardiopulmonary arrests go unwitnessed or unmonitored.1
The aim of this study is to investigate the impact of alarm configuration tactics in general care settings.
Retrospective analysis of over 150,000 hours of medical/surgical unit continuous SpO2 and pulse rate data were used to estimate alarm rates and impact on individual nurses.
Application of an SpO2 threshold of 80% vs 88% produced an 88% reduction in alarms. Addition of a 15 second annunciation delay reduced alarms by an additional 71% with an SpO2 threshold of 80%. Pulse rate alarms were reduced by 93% moving from a pulse rate high threshold of 120–140 bpm, and 95% by lowering the pulse rate low threshold from 60 to 50 bpm. A 15 second annunciation delay at thresholds of 140 bpm and 50 bpm resulted in additional reductions of 80% and 81%, respectively. Combined alarm frequency across all parameters for every 24 hours of actual monitored time yielded a rate of 4.2 alarms for the surveillance configuration, 83.0 alarms for critical care monitoring, and 320.6 alarms for condition monitoring. Total exposure time for an individual nurse during a single shift ranged from 3.6 min with surveillance monitoring, to 1.2 hours for critical care monitoring, and 5.3 hours for condition monitoring.
Continuous monitoring can eliminate unwitnessed/unmonitored arrests associated with significant increased mortality in the general care setting. The “alarm problem” associated with these systems is manageable using alarm settings that signify severely abnormal physiology to alert responsible clinicians of urgent situations.
Fatal outcome of isolated patients who suffered an in-hospital cardiac arrest
2022, Resuscitation
Citation Excerpt :
Mortality is quite high, and a large proportion of those who survive have poor neurological outcomes.1–3 Outcomes are affected by patient characteristics,3–6 as well as the timepoint and location of cardiac arrest.3,5,7 Isolation of patients in single-patient rooms for infection control precautions is a daily practice to reduce the propagation of various infectious agents, such as multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and multidrug-resistant gram-negative bacilli (MRGN).8
Isolation of patients in single-patient rooms for infection control precautions leads to less contact with medical staff. Our objective was to assess whether isolated patients who suffer an in-hospital cardiac arrest (IHCA) have lower survival as non-isolated IHCA patients.
We screened for IHCA occurrence and the isolation state in 75.987 patients that had been hospitalized from 2016 to 2019 at the university hospital. Primary endpoint was survival to discharge. Neurological outcome was assessed using the cerebral performance category scale.
In five consecutive years, 4,249 out of 75,987 patients (5.6%) had to be isolated for infection control precautions. In-hospital cardiac arrest occurred in 32 (0.8%) of these isolated patients and in 410 out of 71,738 non-isolated patients (0.6%) (p = 0.130). Propensity score matching yielded 30 isolated and 30 non-isolated patients who suffered an IHCA, without a difference in baseline characteristics and characteristics of cardiac arrests between the groups. Only one out of 30 isolated patients (3.3%) survived to discharge after IHCA compared to 11 non-isolated patients (36.6%) (risk difference, 33.3% [95% CI, 14.9%–51.7%]. None of the 30 isolated patients were discharged with good neurological outcomes compared to nine out of 30 non-isolated IHCA patients (30%) (risk difference, 30% [95% CI, 13.6%–46.4%]). In the multivariate analysis, patient isolation was an independent predictor of poor survival after IHCA (OR, 18.99; 95% CI, 2.467–133.743).
Isolation of patients for infection control precautions is associated with considerable poorer survival and neurological outcome in case these patients are suffering an IHCA.
Outcomes of in-hospital cardiac arrest among hospitals with and without telemedicine critical care
2022, Resuscitation
Citation Excerpt :
Patient outcomes following IHCA remain extremely poor, with survival to discharge rates of 20% nationwide.2 Further, survival rates are lower for the > 50% of IHCA occurring during nights and weekends,3,4 when the ability of hospital staff to recognize deteriorating patients, prevent IHCA, or quickly initiate resuscitation protocols may be reduced.5,6 Telemedicine Critical Care (TCC) combines audiovisual technologies with electronic medical records access to enable the remote provision of critical care.7
Survival rates following in-hospital cardiac arrest (IHCA) are lower during nights and weekends (off-hours), as compared to daytime on weekdays (on-hours). Telemedicine Critical Care (TCC) may provide clinical support to improve IHCA outcomes, particularly during off-hours.
To evaluate the association between hospital availability of TCC and IHCA survival.
We identified 44,585 adults at 280 U.S. hospitals in the Get With The Guidelines® - Resuscitation registry who suffered IHCA in an Intensive Care Unit (ICU) or hospital ward between July 2017 and December 2019. We used 2-level hierarchical multivariable logistic regression to investigate whether TCC availability was associated with better survival, overall, and during on-hours (Monday–Friday 7:00 a.m.-10:59p.m.) vs. off-hours (Monday–Friday 11:00p.m.-6:59 a.m., and Saturday-Sunday, all day, and US national holidays).
14,373 (32.2%) participants suffered IHCA at hospitals with TCC, and 27,032 (60.6%) occurred in an ICU. There was no difference between TCC and non-TCC hospitals in acute resuscitation survival rate or survival to discharge rates for either IHCA occurring in the ICU (acute survival odds ratio [OR] 1.02, 95% CI 0.92–1.15; survival to discharge OR 0.94 [0.83–1.07]) or outside of the ICU (acute survival OR 1.03 [0.91–1.17]; survival to discharge OR 0.99 [0.86–1.12]. Timing of cardiac arrest did not modify the association between TCC availability and acute resuscitation survival (P =.37 for interaction) or survival to discharge (P =.39 for interaction).
Hospital availability of TCC was not associated with improved outcomes for in-hospital cardiac arrest.
Pulseless electrical activity vs. asystole in adult in-hospital cardiac arrest: Predictors and outcomes
2021, Resuscitation
This observational cohort study aimed to identify factors associated with pulseless electrical activity (PEA) and asystole in in-hospital cardiac arrest (IHCA) patients and to determine whether differences in outcome based on the initial rhythm were explained by patient- and cardiac arrest characteristics.
Adults with IHCA from 2017 to 2018 were included from the Danish IHCA Registry (DANARREST). Additional data came from population-based registries. Unadjusted (RRs) and adjusted risk ratios (aRRs) were estimated for predictors of initial rhythm, return of spontaneous circulation (ROSC), and survival.
We included 1495 PEA and 1285 asystole patients. The patients did not differ substantially in patient characteristics. Female sex, age>90 years, pulmonary disease, and obesity were associated with initial asystole. Ischemic heart disease and witnessed and monitored cardiac arrest were associated with initial PEA. In unadjusted and adjusted analyses, PEA was associated with increased ROSC (aRR = 1.21, 95% confidence interval [CI] 1.10; 1.33). PEA was also associated with increased 30-day and 1-year survival in the unadjusted analysis, while there was no clear association between the initial rhythm and 30-day (aRR = 0.88, 95% CI 0.71; 1.11) and 1-year (aRR = 0.85, 95% CI 0.69; 1.04) survival when patient- and cardiac arrest characteristics were adjusted for.
In patients with IHCA presenting with PEA or asystole, there were no major differences in patient demographics and comorbidities. The patients differed substantially in cardiac arrest characteristics. Initial PEA was associated with higher risk of ROSC, but there was no difference in 30-day and 1-year survival.
Immortal: Our Cells, DNA, and Bodies
2021, Immortal: Our Cells, DNA, and Bodies
Resuscitation outcomes of a wireless ECG telemonitoring system for cardiovascular ward patients experiencing in-hospital cardiac arrest
2021, Journal of the Formosan Medical Association
In-hospital cardiac arrest is a serious issue for hospitalized patients. The documented initial rhythm and detected medical events have been reported to influence the survival of cardiopulmonary resuscitation. This study aimed to identify the effect of continuous real-time electrocardiogram (ECG) monitoring on the prognosis of resuscitated patients in a general cardiac ward.
We conducted this retrospective study using medical records of hospitalized patients in a cardiovascular ward who experienced an in-hospital cardiac arrest and received cardiopulmonary resuscitation from February 2015 to December 2018. The patients who were considered to be at high risk of cardiac events such as ventricular arrhythmia would receive continuous ECG monitoring. A wireless ECG telemonitoring system was introduced to replace traditional bedside ECG monitors. The outcome measures were the initial success of resuscitation, 24-h survival after resuscitation, and survival to discharge.
We enrolled 115 patients with a cardiac arrest during hospitalization, of whom 73 (63%) patients received wireless ECG telemonitoring. Patients receiving continuous ECG monitoring were associated with higher opportunities of initial success of resuscitation and 24-h survival after resuscitation (67.1% vs. 40.5%, p = 0.005; and 49.3% vs. 26.2%, p = 0.015, respectively) when comparing to the non-monitoring group; but no significant difference in survival to discharge (21.9% vs. 16.7%, p = 0.498) was observed. With adjustment of the covariates, the monitoring group was associated with a higher likelihood to reach the initial success of resuscitation (odds ratios [ORs], 3.21; 95% confidence interval [CI], 1.03–9.98). However, the effect of monitoring on 24-h survival and survival to discharge was close to null after adjusting for covariates.
A wireless ECG telemonitoring system were beneficial to the initial success of resuscitation for patients at high risk of cardiovascular events suffering an in-hospital cardiac arrest; but had less impact on 24-h survival and survival to discharge.

View all citing articles on Scopus

^☆: A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.11.020.

¹: See Appendix A for the NRCPR Investigators.

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Clinical paperIn-hospital cardiac arrest: Impact of monitoring and witnessed event on patient survival and neurologic status at hospital discharge☆

Abstract

Context

Objective

Design, setting, and patients

Interventions

Main outcome measures

Results

Conclusions

Introduction

Section snippets

Study data

Results

Comment

Conflict of interest statement

Resuscitation

Resuscitation

Resuscitation

Am J Med

Resuscitation

Am J Emerg Med

Resuscitation

Ann Emerg Med

Resuscitation

Ann Emerg Med

J Am Col Cardiol

Am J Cardiol

Jt Comm J Qual Patient Saf

Appl Nurs Res

Health Policy

Clinical paper
In-hospital cardiac arrest: Impact of monitoring and witnessed event on patient survival and neurologic status at hospital discharge☆