Abstract
AimsWe aimed to describe the characteristics and outcomes of adults admitted to hospital with suspected COVID-19 according to their DNACPR decisions, and identify factors associated with DNACPR decisions. MethodsWe undertook a secondary analysis of 13,977 adults admitted to hospital with suspected COVID-19 and included in the Pandemic Respiratory Infection Emergency System Triage (PRIEST) study. We recorded presenting characteristics and outcomes (death or organ support) up to 30 days. We categorised patients as early DNACPR (before or on the day of admission) or late/no DNACPR (no DNACPR or occurring after the day of admission). We undertook descriptive analysis comparing these groups and multivariable analysis to identify independent predictors of early DNACPR. ResultsWe excluded 1249 with missing DNACPR data, and identified 3929/12748 (31%) with an early DNACPR decision. They had higher mortality (40.7% v 13.1%) and lower use of any organ support (11.6% v 15.7%), but received a range of organ support interventions, with some being used at rates comparable to those with late or no DNACPR (e.g. non-invasive ventilation 4.4% v 3.5%). On multivariable analysis, older age (p < 0.001), active malignancy (p < 0.001), chronic lung disease (p < 0.001), limited performance status (p < 0.001), and abnormal physiological variables were associated with increased recording of early DNACPR. Asian ethnicity was associated with reduced recording of early DNACPR (p = 0.001). ConclusionsEarly DNACPR decisions were associated with recognised predictors of adverse outcome, and were inversely associated with Asian ethnicity. Most people with an early DNACPR decision survived to 30 days and many received potentially life-saving interventions. RegistrationISRCTN registry, ISRCTN28342533, http://www.isrctn.com/ISRCTN28342533
Highlights
In-hospital cardiac arrest is relatively common in patients with COVID19 and often results in poor outcome
We present a post hoc secondary analysis of patients admitted with suspected COVID-19 that aims to describe their characteristics and outcomes according to their do not attempt cardiopulmonary resuscitation (DNACPR) decision and identify factors associated with recording of a DNACPR decision
Most patients (59.4%) with an early DNACPR decision survived to 30 days and 11.6% received some form of organ support
Summary
In-hospital cardiac arrest is relatively common in patients with COVID19 and often results in poor outcome. A multicentre cohort study from the United States[1] reported that 701/5019 (14.0%) critically ill patients with COVID-19 had in-hospital cardiac arrest, with 400/701 (57.1%) receiving CPR, and only 7% of these surviving to hospital discharge with normal or mildly impaired neurological status. Management of cardiac arrest in COVID-19 is further complicated by concerns about infection risk associated with aerosol-generating procedures and consequent risks to staff.[2]. These concerns have raised awareness about the need to consider do not attempt cardiopulmonary resuscitation (DNACPR) decisions when patients are admitted to hospital with suspected COVID-19. Concerns have been raised about inappropriate use of DNACPR decisions during the pandemic,[4] leading to the Care Quality Commission being asked to review their use in the United Kingdom (UK).[5]
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