In-Hospital Cardiac Arrest: How Teams & Time Affect Resuscitation?

This report investigates the impact of in-hospital cardiac arrest teams and the time of day on patient survival following resuscitation efforts. Data was collected from emergency calls between July 2011 and June 2013, focusing on factors such as patient demographics, initial rhythm, duration of resuscitation, and medication administered. The study found that while survival rates following in-hospital resuscitation remain poor, the time of day may have less impact on the quality of resuscitation due to the presence of specialized emergency teams. However, significantly more resuscitations occurred during non-regular working hours, and neuron-specific enolase levels were higher at 72 hours post-resuscitation during these times. Younger patients with an initial shockable rhythm and shorter resuscitation times showed better survival rates. The research emphasizes the importance of early recognition and intervention in improving outcomes for in-hospital cardiac arrest patients.

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Open access Full Text article
http://dx.doi.org/10.2147/IJGM.S66609
cardiac arrest teams and time of day: effects
on surviving in-hospital resuscitation
Martin christ
Wolfgang Dierschke
Katharina Isabel von
auenmueller
Marc van Bracht
Martin Grett
hans-Joachim Trappe
Department of cardiology and
angiology, Marienhospital herne,
ruhr – University Bochum, herne,
Germany
correspondence: Martin christ
Department of cardiology and angiology,
Marienhospital herne, ruhr – University
Bochum, hoelkeskampring 40,
44625 herne, Germany
Tel [phone]
Fax[phone]
email martin.christ@marienhospital-
herne.de
Objectives:Little is known about the factors that influence survival following in-hospital
resuscitation, but previous investigations have suggested that in-hospital resuscitations outside
of regular working hours are associated with worse survival rates.
Material and methods:In-hospital cardiac arrest teams at our hospital were instructed to
complete a questionnaire following every emergency call between July 2011 and June 2013.
Data on all resuscitation attempts were collected and analyzed.
Results:A total of 65 in-hospital resuscitations were recorded in 42 males (64.6%) and
23 females (35.4%) (mean age 72.0 ±14.3 years). A total of 54 (83.1%) cardiac arrests were
witnessed; seven (10.8%) showed a shockable rhythm at the time of the first ECG. Resuscitation
attempts lasted 29.3±41.3 minutes, and 4.1±3.1 mg epinephrine was given. Return of spontaneous
circulation could be achieved in 38 patients (58.5%); 29 (44.6%) survived the first day, 23 (35.4%)
the seventh day, and 15 patients (23.1%) were discharged alive. Significantly more in-hospital
resuscitations were obtained for those performed during non-regular working hours (P, 0.001),
with higher neuron-specific enolase levels at 72 hours after resuscitation during nonregular work-
ing hours (P=0.04). Patients who were discharged alive were significantly younger (P=0.01),
presented more often with an initial shockable rhythm (P=0.04), and had a shorter duration of
resuscitation (P, 0.001) with the need of a lower dose of epinephrine (P, 0.001).
Discussion:Survival rates following in-hospital resuscitation were poor at any time, but
appear to depend less on time-dependent effects of the quality of resuscitation and more on
time-dependent effects of recognition of cardiac arrests.
Keywords:sudden cardiac death, emergency medicine, time of day
Objectives
Previous studies have estimated that a large number of in-hospital cardiac arrests
occur; for example, more than 200,000 in-hospital cardiac arrests occur annually in
the United States.1 Despite this substantial number of patients, only a few studies have
focused on this theme. Factors that have been described as being relevant for surviving
an in-hospital cardiac arrest include an initial shockable rhythm, younger age, shorter
duration of arrest, and time of arrest. 2 Time-dependent effects were also reported in
another large investigation that described lower survival rates of in-hospital cardiac
arrest during nights and weekends.3
Since the implementation of in-hospital cardiac arrest teams during the past few
years, we are of the opinion that the time of an arrest can no longer automatically be
associated with differences in the quality of resuscitation and the outcome following
an in-hospital cardiac arrest. For this reason, we initiated this study to test our
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hypothesis that, due to specialized emergency teams being
available 24 hours a day, there are no time-dependent dif-
ferences in survival of in-hospital cardiac arrest in a good
neurological state.
Material and methods
In-hospital cardiac arrest team
In clinically unstable inpatients, early intervention by a medi-
cal emergency team significantly reduces the incidence of
and mortality from unexpected in-hospital cardiac arrest. 4
Consequently, in our hospital, a central in-hospital cardiac
arrest team was implemented a few years ago. This team
comprises one emergency physician and an experienced
intensive care nurse who are available 24 hours a day by
emergency call and can reach every in-hospital emergency
within 4 minutes.
Data collection
In our hospital, all in-hospital emergency calls initially
reach the coordination center, who then alert the emergency
physician and the intensive care nurse. All emergency calls,
therefore, can be registered in a central database, and our
in-hospital cardiac arrest teams could be instructed to fill
out a questionnaire following every emergency call due
to a cardiac arrest between July 2011 and June 2013. The
questionnaires contained data regarding sex, age, place of
emergency, initial rhythm, and duration of resuscitation,
as well as the number of defibrillations and applied
medication.
Regular working hours were defined as the time between
8 am and 5 pm Monday through Friday, except for holidays.
This threshold was chosen in accordance with the regular
working hours of the physicians in our hospital.
The cardiac arrest was classified as “in-hospital” if it
occurred in a hospitalized patient who had a pulse at the
time of admission. Resuscitation attempts following in-
hospital cardiac arrests were recorded and stored on a central
database. Data were completed by additional review of the
patient records. The primary endpoint of our study was
survival following in-hospital cardiac arrest. The secondary
endpoint was survival in a good neurological state (cerebral
performance category [CPC] 1 or 2). Statistical analyses were
performed using Student’s t-tests and Pearson’s chi-squared
tests with the Statistical Package for the Social Sciences
(SPSS 22.0; IBM, Armonk, NY, USA).
The study adhered to all criteria of the WMA Declaration
of Helsinki – Ethical Principles for Medical Research
Involving Human Subjects.
Results
Patient data
A total of 65 in-hospital resuscitations were recorded between
July 1, 2011, and June 30, 2013, in 42 males (64.6%) and
23 females (35.4%) with a mean age of 72.0±14.3 years. A total
of 54 (83.1%) in-hospital resuscitations followed witnessed
arrests (either directly or indirectly via ECG monitoring); seven
patients (10.8%) presented with an initial shockable rhythm.
Resuscitation attempts lasted 29.3±41.3 minutes, and
4.1±3.1 mg epinephrine was given. Initial return of sponta-
neous circulation (ROSC) could be achieved in 38 patients
(58.5%); 29 (44.6%) survived the first day, 23 (35.4%) the
seventh day, and 15 patients (23.1%) were discharged alive.
Among those discharged, eleven patients (16.9%) showed a
good cerebral performance category (CPC 1), two patients
(3.1%) had moderate disabilities (CPC 2), and two patients
(3.1%) remained in a vegetative state (CPC 4).5
The cause of death was cardiac-related in 36 patients
(55.4%), hypoxemia in 16 patients (24.6%), and other reasons
in 13 patients (20.0%). Neuron-specific enolase (NSE) level
was 57.5±108.8 ng/mL at 24 hours after resuscitation, and
35.7±19.3 ng/mL at 72 hours after resuscitation.
The first electrocardiogram (ECG) after resuscitation
showed heart rates of 90.2±27.6 beats per minute (bpm) and
a frequency-related QT time of 462.1±42.5 ms; maximal
creatinine kinase was 2197.9±1960.0 U/L.
After ROSC, the following were obser ved:
f irst pH =7 . 2 5±0.15, pCO 2 =4 8 . 2±26.6 mmHg,
pO2 =130.3±104.8 mmHg, lactate =5.6±4.8 mmol/L, and
potassium =4.2±0.8 mmol/L (Table 1).
resuscitation during regular
and nonregular working hours
According to the classification of regular and nonregular
working hours as described in the Data collection section,
significantly more in- hospital resuscitations were observed
during nonregular working hours (P, 0.001). No differences
were observed between patients resuscitated during regular
working hours and those resuscitated during nonregular
working hours, except for a significantly higher NSE level at
72 hours after resuscitation during nonregular working hours
(P=0.04; Table 1).
Post hoc analyses depending
on patient follow-up
A comparison of patients who were discharged alive following
in-hospital resuscitation and those who died during follow-up
showed several significant differences (Table 2). Patients who
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Time of day: effects on in-hospital cardiac arrest
were discharged alive were significantly younger (P=0.01),
presented more often with an initial shockable rhythm (P=0.04),
and had a shorter duration of resuscitation (P, 0.001) with the
need for a lower dose of epinephrine (P, 0.001).
Patient characteristics, including first blood gas analysis
and ECG criteria following ROSC, showed no significant
differences.
Discussion
Duration of cardiopulmonary resuscitation, age, initial
rhythm, and witnessed events are factors that have been
described to influence survival of any kind of sudden cardiac
arrest; ie, in-hospital cardiac arrest6 as well as out-of-hospital
cardiac arrest. 7 However, as patients of in-hospital cardiac
arrest are hospitalized due to preexisting illness, they cannot
be directly compared with patients of out-of-hospital cardiac
arrests; for example, acute apoplectic stroke, preexisting
severe sepsis, and preexisting poor CPC scores have been
associated with a very poor prognosis for surviving in-
hospital cardiac arrest in a good neurological state.8
For this reason, further studies were demanded to specifi-
cally focus on in-hospital cardiac arrests, and we initiated our
study to investigate whether the time of arrest still influences
survival from in-hospital cardiac arrest despite the imple-
mentation of in-hospital cardiac arrest teams.
Unfortunately, despite the implementation of in-hospital
cardiac arrest teams, survival rates following in-hospital resus-
citation are poor even with acceptable rates of initial ROSC.2,9–11
In our study, only 23.1% of all resuscitated patients were dis-
charged alive, and only 20.0% of all resuscitated patients left
the hospital in a good neurological state (CPC 1 or 2).
effect of time on survival rates
following in-hospital cardiac arrest
It has been assumed that the time of an arrest may influence
survival rates following in-hospital cardiac arrest, with
Table 1 Patient characteristics
All patients
(n=65)
Regular working
hours (n=25)
Nonregular working
hours (n=40)
P-value
Male, n (%) 42 (64.6) 14 (56.0) 28 (70.0) 0.25
age (years) 72.0±14.3 69.5±13.6 73.6±14.6 0.26
Witnessed event, n (%) 54 (83.1) 21 (84.0) 33 (82.5) 0.88
shockable rhythm, n (%) 7 (10.8) 4 (16.0) 3 (7.5) 0.28
Duration cPr (minutes) 29.3±41.3 35.7±62.1 25.2±19.6 0.42
epinephrine (mg) 4.1±3.1 4.41±3.57 3.88±2.88 0.57
return of spontaneous circulation, n (%) 38 (58.5) 17 (68.0) 21 (52.5) 0.22
expected cause, n (%)
cardiac
hypoxemia
Others
36 (55.4)
16 (24.6)
13 (20.0)
17 (68.0)
5 (20.0)
3 (12.0)
19 (47.5)
11 (27.5)
10 (25.0)
0.36
Mild therapeutic hypothermia (33° c), n (%) 3 (4.6) 0 (0.0) 3 (7.5) 0.28
Survival at first day, n (%) 29 (44.6) 12 (48.0) 17 (42.5) 0.66
survival at seventh day, n (%) 23 (35.4) 11 (44.0) 12 (30.0) 0.25
Discharged alive, n (%) 15 (23.1) 7 (28.0) 8 (20.0) 0.46
nse after 24 hours (ng/ml) 57.5±108.8 31.3±24.5 70.7±132.5 0.38
nse after 72 hours (ng/ml) 35.7±19.3 18.4±3.9 42.6±18.5 0.04
cerebral Performance category, n (%)
1
2
3
4
11 (16.9)
2 (3.1)
0 (0.0)
2 (3.1)
6 (24.0)
1 (4.0)
0 (0.0)
0 (0.0)
5 (12.5)
1 (2.5)
0 (0.0)
2 (5.0)
0.36
heart rate (beats/minute) 90.2±27.6 85.9±26.7 94.3±28.8 0.42
QTc duration (ms) 462.1±42.5 453.0±49.4 470.6±34.4 0.28
creatinine kinase maximum (U/l) 2,197.9±1,960.0 1,276.5±1,418.4 3,119.3±2,098.1 0.11
First ph 7.25±0.15 7.26±0.19 7.25±0.10 0.86
pcO2 (mmhg) 48.2±26.6 48.3±33.9 48.1±20.3 0.98
pO2 (mmhg) 130.3±104.8 145.3±131.5 118.3±80.5 0.54
lactate (mmol/l) 5.6±4.8 6.6±5.4 4.7±4.2 0.33
Potassium (mmol/l) 4.2±0.8 4.2±0.8 4.3±0.8 0.79
Notes: continuous variables are expressed as mean± standard deviation. Bold P-values were considered to be significant.
Abbreviations: CPR, cardiopulmonary resuscitation; NSE, neuron-specific enolase; QTc, frequency-related QT time.
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poorer results obtained for resuscitation performed during
nonregular working hours. 2,3,10 Nevertheless, previous
studies did not consider that 24/7 in-hospital resuscitation
teams might cause comparable conditions for victims of
in-hospital cardiac arrests independent from the time of
an arrest.
In our study, time-dependent effects were minimal;
the only observed difference was a higher NSE level at
72 hours after in-hospital resuscitation during nonregular
working hours, which affected neither the survival rates nor
the neurological outcomes among survivors (Table 1 and
Figure 1). We therefore doubt that the time of resuscitation
has a relevant effect on the efficiency of the resuscitation
procedure itself; at least in hospitals with 24/7 in-hospital
cardiac arrest teams. Following this idea, we think that
lower survival rates from in-hospital cardiac arrest during
nights and weekends may be more a problem of a later
detection of the cardiac arrest. This theory is supported by
the following two findings. First, the nurse-to-bed ratio has
been described as a relevant modifiable factor for survival
following an in-hospital cardiac arrest.12 Second, the median
hospital cardiac arrest incidence rate has been described
as 4.02 per 1,000 admissions, 12 but during our study
period, approximately 35,000 admissions were observed
in our hospital, which would imply that approximately
140 expected in-hospital cardiac arrests were observed
during the same time. Nevertheless, only 65 resuscitation
attempts were identified in our study, suggesting a signifi-
cant percentage of in-hospital cardiac arrests that occurred
without resuscitation attempts. Furthermore, 83.1%, of
cardiac arrests were witnessed in our study, which indicates
that resuscitation attempts were mainly initiated following a
witnessed event. Considering these findings, we think those
previously described effects of time of arrest on survival
rates might be more a problem of delayed recognition rather
than poor resuscitation.
limitations
The main limitation of this study is the small number of
patients. We therefore think that further studies should be
performed to verify our results.
Conclusion
Survival rates following in-hospital resuscitation might
depend less on time-dependent effects of the quality of
resuscitation and more on on time-dependent effects of
recognition. Nevertheless, our single-center results should be
confirmed by further investigations and larger trials.
Table 2 Post hoc analyses depending on patient’s survival during
follow-up
Discharged
alive
(n=15)
Died during
follow-up
(n=50)
P-value
Male, n (%) 9 (60.0) 33 (66.0) 0.76
age (years) 62.9±13.6 74.7±13.4 0.01
Witnessed event, n (%) 14 (93.3) 40 (80.0) 0.43
shockable rhythm, n (%)4 (26.7) 3 (6.0) 0.04
Duration cPr (minutes) 6.7±7.4 36.0±44.9 ,0.001
epinephrine (mg) 1.6±1.2 4.5±3.2 ,0.001
return of spontaneous
circulation, n (%)
15 (100.0) 23 (46.0) ,0.001
expected cause, n (%)
cardiac
hypoxemia
Others
9 (60.0)
5 (33.3)
1 (6.7)
27 (54.0)
11 (22.0)
12 (24.0)
0.27
Mild therapeutic
hypothermia (33° c), n (%)
2 (13.3) 1 (2.0) 0.13
Survival at first day, n (%)15 (100.0) 14 (28.0) ,0.001
survival at seventh day, n (%)15 (100.0) 8 (16.0) ,0.001
Discharged alive, n (%) 15 (100.0) 0 (0.0) ,0.001
nse after 24 hours (ng/ml)92.3±157.2 27.1±14.8 0.32
nse after 72 hours (ng/ml)41.9±21.3 27.3±15.8 0.35
heart rate (bpm) 88.8±28.5 91.1±27.9 0.84
QTc duration (ms) 445.2±41.1 472.4±41.0 0.10
creatinine kinase
maximum (U/l)
2,485.8±1,963.51,992.3±2,086.70.69
First ph 7.30±0.09 7.23±0.17 0.21
pcO2 (mmhg) 43.9±14.3 50.3±31.2 0.47
pO2 (mmhg) 134.1±62.4 128.3±122.3 0.87
lactate (mmol/l) 4.4±3.4 6.1±5.3 0.31
Potassium (mmol/l) 3.97±0.51 4.32±0.86 0.06
Notes: continuous variables are expressed as mean± standard deviation. Bold
P-values were considered to be significant.
Abbreviations: CPR, cardiopulmonary resuscitation; NSE, neuron-specific enolase;
QTc, frequency-related QT time.
80
70
60
50
Percent
40
20
10
0
ROSC Survival seventh
day
All Regular Nonregular
Discharged aliveSurvival first day
30
Figure 1 Patient survival following in-hospital cardiac arrest, depending on the time
of resuscitation (regular versus nonregular working hours).
Abbreviation: rOsc, return of spontaneous circulation.
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Time of day: effects on in-hospital cardiac arrest
Disclosure
The authors report no conflicts of interest in this work.
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