Do patient characteristics or factors at resuscitation influence long-term outcome in patients surviving to be discharged following in-hospital cardiac arrest?

INTRODUCTION: Few studies have focused on factors influencing long-term outcome following in-hospital cardiac arrest. The present study assesses whether long-term outcome is influenced by difference in patient factors or factors at resuscitation. METHODS: An analysis of cardiac arrest data collected from one Swedish tertiary hospital and from five Finnish secondary hospitals supplemented with data on 1 year survival. Multiple logistic regression analysis was used to identify factors associated with survival at 12 months. RESULTS: A total of 441 patients survived to hospital discharge following in-hospital cardiac arrest and 359 (80%) were alive at 12 months. Factors independently associated with survival [odds ratio (OR) >1 indicates increased survival and <1 decreased survival] at 12 months were; age [OR 0.95, 95% confidence interval (CI) 0.93-0.98], renal disease (OR 0.3, CI 0.1-0.9), good functional status at discharge (OR 4.9, CI 1.3-18.9), arrest occurring at (compared with arrests on general wards) emergency wards (OR 4.7, CI 1.4-15.3), cardiac care unit (OR 2.8, CI 1.2-6.4), intensive care unit (OR 2.4, CI 1.1-5.7), ward for thoracic surgery (OR 10.2, CI 2.6-40.1) and unit for interventional radiology (OR 13.3, CI 3.4-52.0). There was no difference in initial rhythm, delay to defibrillation or delay to return of spontaneous circulation between survivors and nonsurvivors. CONCLUSION: Several patient factors, mainly age, functional status and co-morbid disease, influence long-term survival following cardiac arrest in hospital. The location where the arrest occurred also influences survival, but initial rhythm, delay to defibrillation and to return of spontaneous circulation do not.

Treatment and outcome in post-resuscitation care after out-of-hospital cardiac arrest when a modern therapeutic approach was introduced.

BACKGROUND: The outcome among patients who are hospitalised alive after out-of-hospital cardiac arrest is still relatively poor. At present, there are no clear guidelines specifying how they should be treated. The aim of this survey was to describe the outcome for initial survivors of out-of-hospital cardiac arrest when a more aggressive approach was applied. PATIENTS: All patients hospitalised alive after out-of-hospital cardiac arrest in the Municipality of Göteborg, Sweden, during a period of 20 months. RESULTS: Of all the patients in the municipality suffering an out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation (CPR) was attempted (n=375), 85 patients (23%) were hospitalised alive and admitted to a hospital ward. Of them, 65% had a cardiac aetiology and 50% were found in ventricular fibrillation. In 32% of the patients, hypothermia was attempted, 28% underwent a coronary angiography and 21% had a mechanical revascularisation. In overall terms, 27 of the 85 patients who were brought alive to a hospital ward (32%) survived to 30 days after cardiac arrest. Survival was only moderately higher among patients treated with hypothermia versus not (37% versus 29%; NS), and it was markedly higher among those who had early coronary angiography versus not (67% versus 18%; p<0.0001). CONCLUSION: In an era in which a more aggressive attitude was applied in post-resuscitation care, we found that the survival (32%) was similar to that in previous surveys. However, early coronary angiography was associated with a marked increase in survival and might be of benefit to many of these patients. Larger registries are important to further confirm the value of hypothermia in representative patient populations.

Variability in survival after in-hospital cardiac arrest depending on the hospital level of care.

BACKGROUND: Survival after in-hospital cardiac arrest (IHCA) differs considerably between hospitals. This study tries to determine whether this difference is due to patient selection because of the hospital level of care or to effective resuscitation management. METHODS: Prospectively collected data on management of in-hospital cardiac arrests from Sahlgrenska Hospital, a tertiary hospital in Gothenburg, Sweden (cohort one) and from five Finnish secondary hospitals (cohort two). A multiple logistic regression model was created for predicting survival to hospital discharge. RESULTS: A total of 954 cases from Sahlgrenska Hospital and 624 patients from the hospitals in Finland were included. The delay to defibrillation was longer at Sahlgrenska than at the five Finnish secondary hospitals (p=0.045). Significant predictors of survival were: (1) age below median (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.5-2.8); (2) no diabetes (OR 1.9, CI 1.2-2.9); (3) arrests occurring during office hours (OR 1.5, CI 1.1-2.2); (4) witnessed cardiac arrest (OR 6.3, CI 2.6-15.3); (5) ventricular fibrillation or ventricular tachycardia as the initial rhythm (OR 4.9, CI 3.5-6.7); (6) location of the arrest (compared to arrests in general wards, GW): thoracic surgery and heart transplantation ward (OR 2.9, CI 1.5-5.9), interventional radiology (OR 4.8, CI 1.9-12.0) and other in-hospital locations (3.0, CI 1.6-5.7) and (7) hospital (compared to arrests at Sahlgrenska Hospital); arrests at Etelä-Karjala Central Hospital [CH] (OR 0.3, CI 0.1-0.7), Päijät-Hame CH (OR 0.3, CI 0.1-0.8) and Seinäjoki CH (OR 0.4, CI 0.3-0.7). CONCLUSION: The comparison of survival following IHCA between different hospitals is difficult, there seems to be undefined factors greatly associated with outcome. A great variability in survival within different hospital areas probably because of differences in patient selection, patient surveillance and resuscitation management was also noted. A locally implemented strong in-hospital chain of survival is probably the only way to improve outcome following IHCA.

Assessment of CPR-D skills of nurses in Göteborg, Sweden and Espoo, Finland: teaching leadership makes a difference.

INTRODUCTION: Construction of an effective in-hospital resuscitation programme is challenging. To document and analyse resuscitation skills assessment must provide reliable data. Benchmarking with a hospital having documented excellent results of in-hospital resuscitation is beneficial. The purpose of this study was to assess the resuscitation skills to facilitate construction of an educational programme. MATERIALS AND METHODS: Nurses working in a university hospital Jorvi, Espoo (n=110), Finland and Sahlgrenska University Hospital, Göteborg (n=40), Sweden were compared. The nurses were trained in the same way in both hospitals except for the defining and teaching of leadership applied in Sahlgrenska. Jorvi nurses are not trained to be, nor do they act as, leaders in a resuscitation situation. Their cardiopulmonary resuscitation (CPR) skills using an automated external defibrillator (AED) were assessed using Objective Structured Clinical Examination (OSCE) which was build up as a case of cardiac arrest with ventricular fibrillation (VF) as the initial rhythm. The subjects were tested in pairs, each pair alone. Group-working skills were registered. RESULTS: All Sahlgrenska nurses, but only 49% of Jorvi nurses, were able to defibrillate. Seventy percent of the nurses working in the Sahlgrenska hospital (mean score 35/49) and 27% of the nurses in Jorvi (mean score 26/49) would have passed the OSCE test. Statistically significant differences were found in activating the alarm (P<0.001), activating the AED without delay (P<0.01), setting the lower defibrillation electrode correctly (P<0.001) and using the correct resuscitation technique (P<0.05). The group-working skills of Sahlgrenska nurses were also significantly better than those of Jorvi nurses. CONCLUSIONS: Assessment of CPR-D skills gave valuable information for further education in both hospitals. Defining and teaching leadership seems to improve resuscitation performance.

Measurement of skills in cardiopulmonary resuscitation--do professionals follow given guidelines?

Since it is suggested that only effective cardiopulmonary resuscitation (CPR) improves survival rates, quality control of training outcomes is important and comparisons between different training methods are desirable. The aim of this study was to test a model of quality assurance, consisting of a computer program combined with the Brennan et al. checklist, for evaluation of CPR performance. A small group of trained medical professionals (cardiac care unit nurses) (n = 10) was used in this pilot study. The result points out several points of concern: half of the participants did not open the airway prior to breathing control. Over 90% of all inflations were 'too fast' and 71% were 'too much'. Only 6.5% of the inflations were correct. On average, the participants made 5.4 inflations per minute. Concerning chest compressions, 40% were 'too deep' while only 4% were 'too shallow'. In spite of the fact that the participants had an average rate at 95 compressions per minute the number of compressions varied between 32 and 51 during 1 minute. When new guidelines are discussed, it would be beneficial if they were tested by a number of people to investigate if following the guidelines is at all possible.