Journal of Biomedical Translational Research

Research Institute of Veterinary Medicine, Chungbuk National University

J Biomed Transl Res 2023; 24(2):53-59

pISSN: 2508-1357, eISSN: 2508-139X

DOI: https://doi.org/10.12729/jbtr.2023.24.2.53

Original Article

Overview of in-hospital cardiac arrests in a 3-year period

Hoon Kang¹^,²^,^*

, Junghee Choi²

, Jeongeun Moon²

¹Department of Anesthesiology and Pain Medicine, College of Medicine, Chungbuk National University, Cheongju 28644, Korea

²Department of Anesthesiology and Pain Medicine, Chungbuk National University Hospital, Cheongju 28644, Korea

^*Corresponding author: Hoon Kang, Department of Anesthesiology and Pain Medicine, College of Medicine, Chungbuk National University, Cheongju 28644, Korea, Tel: +82-43-269-6231, E-mail: hkang118@chungbuk.ac.kr

Received: Jun 02, 2023; Revised: Jun 15, 2023; Accepted: Jun 16, 2023

Abstract

Patients experiencing out-of-hospital cardiac arrest (OOHCA) during the weekend are less likely to survive to hospital admission than those experiencing OOHCA on weekdays. We aimed to determine whether the survival rates of in-hospital cardiac arrest (IHCA) were lower on weekends than on weekdays. We comprehensively reviewed the records of patients who experienced IHCA at CBNUH between 2018 and 2020. A total of 861 IHCAs occurred during the study period; these data included recurrent IHCA cases, as some patients experienced more than one IHCA. Of these, 739 IHCA cases were included in the survival analysis, and the survival rate was 65.2%, which is higher than the rate reported in a previous study. There were no differences in the survival rate between weekdays and weekends. Additionally, the time of day at which IHCA occurred and pre-IHCA intubation status did not affect survival. Patients in wards were less likely to survive than those in intensive care units (60.0% vs. 66.0%). Although pre-IHCA intubation did not show any added value in preventing sudden cardiac arrests, meticulous patient care and monitoring in terms of intra- or extrapulmonary oxygen therapy is needed, as is the promotion of cardio-pulmonary-cerebral resuscitation (CPCR) equipment availability and quick rescuer responses for patients with IHCA. Our findings may be of value in improving CPCR guidelines and monitoring patients at risk of IHCA.

Keywords: in-hospital cardiac arrest; out-of-hospital cardiac arrest; cardiopulmonary resuscitation; survival outcomes; outcome studies

INTRODUCTION

Cardiac arrest is a leading cause of mortality, with a survival rate of only 12% [1]. In the United States, cardiac arrests were significantly more likely to occur on Saturdays than on other days [1]. Further, patients experiencing out-of-hospital cardiac arrest (OOHCA) during the weekend were 20% less likely to survive hospital admission than those experiencing OOHCA on a weekday. The reduced survival rates for weekends may be due to a decrease in staffing on weekends. In-hospital cardiac arrest (IHCA) is common and often fatal [2]. Despite significant attention to resuscitation in hospitals, national data on trends in the incidence and survival rates of IHCA are limited [3].

Considering that the survival rates for OOHCA are lower during the weekend than on weekdays, we retrospectively reviewed IHCA records to see if this trend was also observed for IHCA. We also investigated factors related to IHCA that could help in improving cardio-pulmonary-cerebral resuscitation (CPCR) guidelines and monitoring patients at risk of IHCA.

MATERIALS AND METHODS

We retrospectively reviewed electronic medical records to identify cases of IHCA based on anonymous patient identification numbers. To determine factors that may influence the occurrence and survival rates of IHCA, we analyzed data from 3 years for the following items, regardless of the cause of hospitalization: clinical department, unit (ward or intensive care unit [ICU]), day of admission (weekday or weekend), time of admission, time from IHCA to CPCR code announcement, time from IHCA to CPCR initiation, pre-IHCA intubation status, number of intubation attempts after IHCA, and CPCR outcome (death or survival).

RESULTS

A total of 861 IHCAs occurred at CBNUH between 2018 and 2020 (327, 277, and 257 admissions in 2018, 2019, and 2020, respectively). Of these, 739 IHCA cases were included in the analysis of clinical outcome (recovery or survival), because the clinical outcomes of 122 IHCA cases were not mentioned in the medical records. All 861 IHCA cases were included in the descriptive analysis of demographic data; these data included recurrent IHCA cases, as some patients experienced IHCA 2–5 times.

The mean age of the participants was 68.5 years, with a male predominance (65.0% men). The survival rate was 65.2%, although this was not the rate of survival to hospital discharge. Almost 72% of the IHCAs occurred on weekdays. However, the survival rate did not differ between weekdays and weekends (64.8% vs. 66.1%, chi-square test, Fig. 1). The time of day at which IHCA occurred (Fig. 2) and pre-IHCA intubation status (Fig. 3) did not affect survival. The patients admitted to wards were less likely to survive than those admitted to ICUs (60.0% vs. 66.0%, p<0.05, Fig. 4). The time from IHCA to CPCR code announcement and time from IHCA to CPCR initiation, pre-IHCA intubation status, clinical department, and number of intubation attempts after IHCA were not significant.

Fig. 1. Clinical outcomes of in-hospital cardiac arrest (IHCA) on weekdays and weekends.

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Fig. 2. Clinical outcomes of in-hospital cardiac arrest (IHCA) according to the time of day.

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Fig. 3. Clinical outcomes of in-hospital cardiac arrest (IHCA) by pre-IHCA intubation status.

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Fig. 4. Clinical outcomes of in-hospital cardiac arrest (IHCA) in wards and intensive care units (ICUs). ^*p<0.05 compared with patients in ICUs who survived.

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DISCUSSION

In this study, patients who experienced IHCA on weekends (66.1%) had slightly higher survival rate than those who experienced IHCA on weekdays (64.8%), although this was not statistically significant. This differs from the results of a previous study that reported lower survival on weekends than on weekdays [4]. Further studies should identify factors, other than the considerably fewer cardiac arrests on weekends than on weekdays (almost 72% of IHCAs occurred on a weekday), that can influence this finding; this will help reduce the differences in survival rate between weekdays and weekends and improve the survival rate.

This study included 861 cases of IHCA. Patients with IHCA are reportedly older, are more often women, and more frequently have witnessed ventricular fibrillation (VF) than patients with OHCA [4]. However, this study did not compare OHCA and IHCA data or evaluate the type of rhythm, such as (VF, ventricular tachycardia [VT], or cardiac standstill, and witness status, which can be valuable in predicting the patients' prognosis and guiding treatments such as early defibrillation.

The incidence of IHCA is seldom reported in the literature. It ranges from 1 to 5 events per 1,000 hospital admissions [5–7] or 0.175 events/bed annually [8]. These rates are consistent with our results of 1.2–1.3 IHCAs per 1,000 hospital admissions per year at CBNUH in 2018–2020.

Reported rates of survival to hospital discharge in patients with cardiac arrest vary greatly, from 0% to 42%, with most reports mentioning rates between 15% and 20% [8–12]. This study evaluated the post-resuscitation clinical outcome in terms of death or survival and did not include following the patients who survived up to discharge. In this study, of 739 IHCA events, 65.2% ended in survival, although this was not the rate of survival to hospital discharge, and the rate was higher than that in a previous study [13]. Various pre–cardiac arrest patient comorbidities have been reported as probable prognostic factors. The Pre-Arrest Morbidity Score [14] and Prognosis After Resuscitation Score [15] have been proposed as instruments for predicting failure to survive after IHCA; however, they have not been prospectively validated. Despite this, these comorbidities are highly related to poor prognosis or survival [16–18]. The patients in this study had similar major comorbidities as those in previous studies, including chronic heart diseases, chronic pulmonary diseases, cerebrovascular diseases, sepsis, malignant neoplasm, and end-stage renal disease. Intra-arrest factors, such as VF or VT as the first recorded rhythm, are also thought to affect the post-resuscitation prognosis of patients with cardiac arrest. Prompt initiation of CPCR or defibrillation after the detection of cardiac arrest is reasonably and strongly associated with good patient outcomes [5, 8, 9, 12, 19–21]. This is important because patients with IHCA more frequently have VF than those with OHCA [3], and only 25%–35% of patients with IHCA have VF or VT [7, 8, 10, 22, 23].

Approximately one in eight patients had another IHCA subsequently, and the patients who only experienced one IHCA had better resuscitation outcomes than those who experienced recurrent IHCA [24]. These results provide clinicians managing patients with recurrent IHCA with crucial prognostic information and help them make decisions regarding resuscitation and end-of-life care. In this study, irrespective of survival, DNR (do not resuscitate) and patient care withdrawal rates were the lowest for patients with recurrent IHCA. Our study also included some patients with recurrent IHCA (2–5 recurrences). Because of the inaccuracy of the data, we could not conduct a precise analysis of the survival rate of patients with recurrent IHCA, but we presume that their outcomes were worse than those of patients without recurrent IHCA.

CONCLUSION

In this study, the survival rates of patients with IHCA did not differ between the weekend and weekdays. Nevertheless, meticulous patient care and monitoring in terms of intr- or extrapulmonary oxygen therapy is needed, as is the promotion of CPCR equipment availability and quick rescuer responses for patients with IHCA. Based on the rates of survival after IHCA or OHCA, patients with moderate or severe comorbidity burdens have a low chance of surviving. However, the active and early initiation of CPCR and using a team-based approach improved IHCA survival in our hospital. Prospective trials are needed to establish the efficacy of standardized CPCR training programs in improving patient survival after cardiac arrest.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Acknowledgements

This work was supported by the research grant of the Chungbuk National University Hospital in 2021.

Ethics Approval

This research has been approved by the Institutional Review Board of Chungbuk National University Hospital, Korea (IRB FILE No : 2021-06-017-001).

REFERENCES

El Asmar A, Dakessian A, Bachir R, El Sayed M. Out of hospital cardiac arrest outcomes: impact of weekdays vs weekends admission on survival to hospital discharge. Resuscitation 2019;143:29-34.

Qazi AH, Kennedy K, Bradley SM, Chan PS. Impact of timing of cardiac arrest during hospitalization on survival outcomes and subsequent length of stay. Resuscitation 2017;121:117-122.

Bradley SM, Kaboli P, Kamphuis LA, Chan PS, Iwashyna TJ, Nallamothu BK. Temporal trends and hospital-level variation of inhospital cardiac arrest incidence and outcomes in the veterans health administration. Am Heart J 2017;193:117-123.

Fredriksson M, Aune S, Bång A, Thorén AB, Lindqvist J, Karlsson T, Herlitz J. Cardiac arrest outside and inside hospital in a community: mechanisms behind the differences in outcome and outcome in relation to time of arrest. Am Heart J 2010;159:749-756.

Skogvoll E, Isern E, Sangolt GK, Gisvold SE. In-hospital cardiopulmonary resuscitation: 5 years’ incidence and survival according to the Utstein template. Acta Anaesthesiol Scand 1999;43:177-184.

Hodgetts TJ, Kenward G, Vlackonikolis I, Payne S, Castle N, Crouch R, Ineson N, Shaikh L. Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital. Resuscitation 2002;54:115-123.

Sandroni C, Ferro G, Santangelo S, Tortora F, Mistura L, Cavallaro F, Caricato A, Antonelli M. In-hospital cardiac arrest: survival depends mainly on the effectiveness of the emergency response. Resuscitation 2004;62:291-297.

Peberdy MA, Kaye W, Ornato JP, Larkin GL, Nadkarni V, Mancini ME, Berg RA, Nichol G, Lane-Trultt T. Cardiopulmonary resuscitation of adults in the hospital: a report of 14 720 cardiac arrests from the national registry of cardiopulmonary resuscitation. Resuscitation 2003; 58:297-308.

Gwinnutt CL, Columb M, Harris R. Outcome after cardiac arrest in adults in UK hospitals: effect of the 1997 guidelines. Resuscitation 2000;47:125-135.

10.

Cooper S, Cade J. Predicting survival, in-hospital cardiac arrests: resuscitation survival variables and training effectiveness. Resuscitation 1997;35:17-22.

11.

de Vos R, de Haes HCJM, Koster RW, de Haan RJ. Quality of survival after cardiopulmonary resuscitation. Arch Intern Med 1999;159:249-254.

12.

Nadkarni VM, Larkin GL, Peberdy MA, Carey SM, Kaye W, Mancini ME, Nichol G, Lane- Truitt T, Potts J, Ornato JP, Berg RA, National Registry of Cardiopulmonary Resuscitation Investigators. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. J Am Med Assoc 2006;295:50-57.

13.

Peberdy MA, Ornato JP, Luke Larkin G, Scott Braithwaite R, Michael Kashner T, Carey SM, Meaney PA, Cen L, Nadkarni VM, Praestgaard AH, Berg RA, National Registry of Cardiopulmonary Resuscitation Investigators. Survival from in-hospital cardiac arrest during nights and weekends. J Am Med Assoc 2008;299:785-792.

14.

O’Keeffe S, Ebell MH. Prediction of failure to survive following in-hospital cardiopulmonary resuscitation: comparison of two predictive instruments. Resuscitation 1994;28:21-25.

15.

Ebell MH. Prearrest predictors of survival following in-hospital cardiopulmonary resuscitation: a meta-analysis. J Fam Pract 1992;34:551-558.

16.

Ballew KA, Philbrick JT, Caven DE, Schorling JB. Predictors of survival following in-hospital cardiopulmonary resuscitation: a moving target. Arch Int Med 1994;154:2426-2432.

17.

de Vos R, Koster RW, de Haan RJ, Oosting H, van der Wouw PA, Lampe-Schoenmaeckers AJ. In-hospital cardiopulmonary resuscitation: prearrest morbidity and outcome. Arch Intern Med 1999;159:845-850.

18.

Sowden GR, Robins DW, Baskett PJF. Factors associated with survival and eventual cerebral status following cardiac arrest. Anaesthesia 1984;39:39-43.

19.

Skrifvars MB, Rosenberg PH, Finne P, Halonen S, Hautamäki R, Kuosa R, Niemelä H, Castrén M. Evaluation of the in-hospital Utstein template in cardiopulmonary resuscitation in secondary hospitals. Resuscitation 2003;56:275-282.

20.

Cooper S, Janghorbani M, Cooper G. A decade of in-hospital resuscitation: outcomes and prediction of survival? Resuscitation 2006;68:231-237.

21.

Andréasson AC, Herlitz J, Bång A, Ekström L, Lindqvist J, Lundström G, Holmberg S. Characteristics and outcome among patients with a suspected in-hospital cardiac arrest. Resuscitation 1998;39:23-31.

22.

Myrianthefs P, Kalafati M, Lemonidou C, Minasidou E, Evagelopoulou P, Karatzas S, Baltopoulos G. Efficacy of CPR in a general, adult ICU. Resuscitation 2003;57:43-48.

23.

Sandroni C, Cavallaro F, Ferro G, Fenici P, Santangelo S, Tortora F, Conti G. A survey of the in-hospital response to cardiac arrest on general wards in the hospitals of Rome. Resuscitation 2003;56:41-47.

24.

Chan ML, Spertus JA, Tang Y, Starks MA, Chan PS. Implications of a recurrent in-hospital cardiac arrest on survival and neurological outcomes. Am Heart J 2018;202:139-143.