Acute Public Hospitals Research Articles

Antipsychotic prescription amongst hospitalized patients with dementia.

Antipsychotic drugs are used to treat behavioural and psychological symptoms of dementia, despite significant safety concerns regarding increased risk of stroke and mortality. The numbers of patients with dementia and related behavioural symptoms being treated in acute hospitals is increasing. (i) to determine pre-admission and in-hospital prevalence of antipsychotic use in a national sample of patients with dementia and acute illness; (ii) identify reasons for antipsychotic use; (iii) assess features of the ward environment which impact on patients with dementia; (iv) determine availability of dementia-specific policies, training, appraisal and mentorship programs which influence service delivery. Four-part standardized audit in 35 public acute hospitals comprising (i) retrospective healthcare record review (n = 660); (ii) prospective assessment of ward environment (n = 77); (iii) ward organization interview with clinical managers (n = 77); (iv) hospital organisation interview with senior managers (n = 35). Antipsychotic drugs were prescribed to 29% of patients with dementia before hospitalization and to 41% during hospitalization; one quarter received new or additional prescriptions. Assessments for delirium (45%), dementia symptoms (39%), mood (26%), mental state (64%) and distress-provoking factors (3%) were suboptimal. Drug indications were documented in 78%. Non-pharmacological interventions were not documented. Most wards lacked environmental cues to promote orientation. Dementia-specific care pathways existed in 2 of 35 hospitals. Staff support and training programmes were suboptimal. 12% of patients were discharged with new antipsychotic prescriptions. Antipsychotic medications are commonly prescribed for hospitalized patients with dementia in Ireland. Ward environments and dementia-related governance structures are suboptimal.

Incidence and Variation of Discrepancies in Recording Chronic Conditions in Australian Hospital Administrative Data.

Diagnostic data routinely collected for hospital admitted patients and used for case-mix adjustment in care provider comparisons and reimbursement are prone to biases. We aim to measure discrepancies, variations and associated factors in recorded chronic morbidities for hospital admitted patients in New South Wales (NSW), Australia. Of all admissions between July 2010 and June 2014 in all NSW public and private acute hospitals, admissions with over 24 hours stay and one or more of the chronic conditions of diabetes, smoking, hepatitis, HIV, and hypertension were included. The incidence of a non-recorded chronic condition in an admission occurring after the first admission with a recorded chronic condition (index admission) was considered as a discrepancy. Poisson models were employed to (i) derive adjusted discrepancy incidence rates (IR) and rate ratios (IRR) accounting for patient, admission, comorbidity and hospital characteristics and (ii) quantify variation in rates among hospitals. The discrepancy incidence rate was highest for hypertension (51% of 262,664 admissions), followed by hepatitis (37% of 12,107), smoking (33% of 548,965), HIV (27% of 1500) and diabetes (19% of 228,687). Adjusted rates for all conditions declined over the four-year period; with the sharpest drop of over 80% for diabetes (47.7% in 2010 vs. 7.3% in 2014), and 20% to 55% for the other conditions. Discrepancies were more common in private hospitals and smaller public hospitals. Inter-hospital differences were responsible for 1% (HIV) to 9.4% (smoking) of variation in adjusted discrepancy incidences, with an increasing trend for diabetes and HIV. Chronic conditions are recorded inconsistently in hospital administrative datasets, and hospitals contribute to the discrepancies. Adjustment for patterns and stratification in risk adjustments; and furthermore longitudinal accumulation of clinical data at patient level, refinement of clinical coding systems and standardisation of comorbidity recording across hospitals would enhance accuracy of datasets and validity of case-mix adjustment.

Electronic Health Records Adoption By European Hospitals: A Configurational Analsyis

Electronic Health Records (EHRs) are considered critical for the delivery of high quality healthcare, saving time, money and lives. As well, their effects on hospitals' processes depend on the patterns of functional capabilities that are used by clinicians and allied healthcare professionals. However, our knowledge of patterns of EHR functional capabilities is limited and most available studies have been conducted within the confines of the United States. Based on data from a European Union region-wide survey, we used factor analysis and a combination of hierarchical and non-hierarchical clustering algorithms followed by discriminant analysis to identify patterns of European Acute Care public hospitals based on clinical functional capabilities made available to clinicians. We empirically derive a 3-cluster solution, composed of three well-separated groups, from a data set of 1056 European Acute Care Hospitals. Statistically, differences in hospitals’ characteristics were found among clusters. From a pract...

Trends and disparities in sepsis hospitalisations in Victoria, Australia.

Objective The aim of the present study was to determine the clinical and epidemiological characteristics of patients with sepsis admitted to hospitals in Victoria, Australia, during the period 2004-14. The data include incidence, severity and mortality. Methods In all, 44222 sepsis hospitalisations were identified between 2004-05 and 2013-14 from the Victorian Admitted Episodes Dataset. The dataset contains clinical and demographic information on all admissions to acute public and private hospitals. Using the International Classification of Diseases (10th Revision) Australian Modification codes, incidence rates, severity of disease and mortality were calculated. Results Sepsis hospitalisation rates per 10000 population increased significantly (P<0.01) over the period, from 6.9 (95% confidence interval (CI) 5.6-7.8) to 10.0 (95% CI 9.1-11.1), an annual growth rate of 3.8%. The age-standardised in-hospital death rates per 100000 population grew significantly (P<0.01) from 9.2 (95% CI 7.8-10.4) in 2004-05 to 13.0 (95% CI 11.7-14.6) in 2013-14, an annual growth rate of 3.1%. Among people under 45 years of age, the 0-4 years age group had the highest hospitalisation rate (3.0 per 10000 population; 95% CI 2.7-3.4). Nearly half (46.2%) of all sepsis hospitalisations were among patients born overseas, with a rate of 14.5 per 10000 population (95% CI 12.4-16.2) in that group compared with a rate of 5.9 per 10000 population (95% CI 5.3-6.7) for patients born in Australia. The age-standardised sepsis hospitalisation rate was 2.6-fold greater in the lowest compared with highest socioeconomic areas (12.7 per 10000 population (95% CI 11.2-13.8) vs 4.8 per 10000 population (95% CI 4.1-5.7), respectively). Conclusion This paper shows a significant upward trend in both sepsis separation rates and in-hospital death rates over the period; unlike sepsis, in-hospital death rates from all diagnoses fell over the same period. The results can be used to stimulate review of clinical practice. Greater understanding of the epidemiology of sepsis could improve care quality and outcomes. What is known about the topic? Sepsis is associated with high mortality rates and severe sepsis is the most common cause of death in intensive care units (ICU). The last published study of sepsis in Victoria (in 2005) showed a gradual rise in rates; since then, there is little information as to whether there has been any significant improvement in treatment outcomes. What does this paper add? This paper provides new information by analysing trends and variations in sepsis hospitalisations in Victoria by several demographic groups from 2004-05 to 2013-14. What are the implications for practitioners? Patients with severe sepsis consume approximately half the ICU resources. Reliable and recent data on the growth of this disease are important for prevention, allocation of resources and to track the effectiveness of care. A key area for intervention is promoting greater adherence to clinical guidelines.

Public hospitals in financial distress: Is privatization a strategic choice?

As safety net providers, public hospitals operate in more challenging environments than private hospitals. Such environments put public hospitals at greater risk of financial distress, which may result in privatization and deterioration of the safety net. The purpose of this study was to investigate whether financial distress is associated with privatization among public hospitals. We used panel data merged from the American Hospital Association Annual Survey, Medicare Cost Reports, Area Resource File, and Local Area Unemployment Statistics. Our study population consisted of all U.S. nonfederal acute care public hospitals in 1997 tracked through 2009, resulting in 6,426 hospital-year observations. The dependent variable "privatization" was defined as conversion from public status to either private not-for-profit or private for-profit status. The main independent variable, "financial distress," was based on the Altman Z-score methodology. Control variables included market and organizational factors. Two random-effects logistic regression models with state and year fixed-effects were constructed. The independent and control variables were lagged by 1 year and 2 years for Models 1 and 2, respectively. Public hospitals in financial distress had greater odds of being privatized than public hospitals not in financial distress: (OR = 4.53, p < .001) for Model 1 and (OR = 3.05, p = .001) for Model 2. Privatization eases access to resources and may provide financial relief to government entities from the burden of continuously funding a hospital operating at a loss, which in turn may help keep the hospital open and preserve access to care for the community. Privatizing a financially distressed public hospital may be a better strategic alternative than closure. The Altman Z-score could be used as a managerial tool to monitor hospitals' financial condition and take corrective actions.

Preparedness of Hospitals in the Republic of Ireland for an Influenza Pandemic, an Infection Control Perspective.

BackgroundWhen an influenza pandemic occurs most of the population is susceptible and attack rates can range as high as 40–50 %. The most important failure in pandemic planning is the lack of standards or guidelines regarding what it means to be ‘prepared’. The aim of this study was to assess the preparedness of acute hospitals in the Republic of Ireland for an influenza pandemic from an infection control perspective.MethodsThis was a cross sectional study involving a questionnaire completed by infection control nurses, time period from June – July 2013, (3 weeks) from acute public and private hospitals in the Republic of Ireland. A total of 46 out of 56 hospitals responded to the questionnaire.ResultsFrom a sample of 46 Irish hospitals, it was found that Irish hospitals are not fully prepared for an influenza pandemic despite the 2009 Influenza A (H1N1) pandemic. In 2013, thirty five per cent of Irish hospitals have participated in an emergency plan or infectious disease exercise and have plans or been involved in local planning efforts to care for patients at non-health care facilities. Sixty per cent of Irish hospitals did not compile or did not know if the hospital had compiled a “lessons learned” from any exercise that were then used to revise emergency response plans. Fifty two per cent of hospitals have sufficient airborne isolation capacity to address routine needs and have an interim emergency plan to address needs during an outbreak. Fifty one percent of hospitals have taken specific measures to stockpile or have reserve medical supplies e.g. masks, ventilators and linen.ConclusionsThis is the first study carried out in the Republic of Ireland investigating the current preparedness for an influenza pandemic from an infection control perspective.Deficits exist in the provision of emergency planning committees, testing of emergency plans, airborne isolation facilities, stockpiling of personal protective equipment (PPE) and medical supplies and organisational schemes/incentives for healthcare workers to continue to work in a pandemic. While Irish standards are comparable to findings from international studies, the health care service needs to continue to enhance preparedness for an influenza pandemic and implement standard preparedness guidance for all Irish hospitals.

Counting the costs of accreditation in acute care: an activity-based costing approach

ObjectivesTo assess the costs of hospital accreditation in Australia.DesignMixed methods design incorporating: stakeholder analysis; survey design and implementation; activity-based costs analysis; and expert panel review.SettingAcute care hospitals accredited by the...

Prospective outcomes in patients with acute exacerbations of chronic obstructive pulmonary disease presenting to hospital: a generalisable clinical audit.

To determine predictors of short- and long-term outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) (AECOPD) presenting to hospital. A prospective clinical audit of AECOPD attendances to the only public acute general hospital in Southern Tasmania, Australia. Out of 416 attendances with AECOPD to the emergency department (ED) between November 2006 and July 2008, 150 patients with 218 attendances were followed to March 2009. Predictors of hospital admission from ED, in-hospital death, length of hospital stay, post-discharge mortality and re-attendance rate for AECOPD were the main outcomes. There were no clear differences between patients admitted to hospital and those sent home from ED. Predictors of in-hospital death were initial physiologic parameters, that is, arterial pH, PaCO2 , oxygen saturation and blood pressure. Longer hospital stay was associated with older age, current smoking, hyperglycaemia, lower blood pressure and lower oxygen saturation. Risk of mortality after discharge was associated with a history of myocardial infarction, nursing home residence and severity of COPD. Re-attendance rate was associated with osteoporosis, younger age and severity of COPD. Further investigation into the process of decision making about which AECOPD patients are admitted from the ED is required. Short-term outcomes, in-hospital death and length of hospital stay are mainly predicted by severity of the acute exacerbation and patient demographics. Although severity of COPD was a predictor of long-term outcomes, the main predictors of these were presence of co-morbidities.

Rounding, work intensification and new public management.

In this study, we argue that contemporary nursing care has been overtaken by new public management strategies aimed at curtailing budgets in the public hospital sector in Australia. Drawing on qualitative interviews with 15 nurses from one public acute hospital with supporting documentary evidence, we demonstrate what happens to nursing work when management imposes rounding as a risk reduction strategy. In the case study outlined rounding was introduced across all wards in response to missed care, which in turn arose as a result of work intensification produced by efficiency, productivity, effectiveness and accountability demands. Rounding is a commercially sponsored practice consistent with new public management. Our study illustrates the impact that new public management strategies such as rounding have on how nurses work, both in terms of work intensity and in who controls their labour.

Nursing management of aggression in a Singapore emergency department: A qualitative study

In Singapore, anecdotal evidence suggests that nurses are concerned about managing aggressive incidents in the emergency department. In this study, registered nurses' perceptions of managing aggressive patients in an emergency department were explored. Ten registered nurses from the emergency department of an acute public hospital in Singapore were interviewed. Four overarching themes emerged from the thematic analysis: (i) impact of aggressive patients on nurses; (ii) nursing assessment of aggressive behaviors; (iii) nursing management of aggressive behaviors; and (iv) organizational support and responsiveness. Further research is required to better support nurses to deliver optimal care for aggressive patients and achieve positive and effective outcomes.

Prevalence of Chronic Kidney Disease in Adults with Type 2 Diabetes Mellitus

Diabetes mellitus (DM) is a major cause of chronic kidney disease (CKD). The epidemiology of CKD secondary to type 2 DM (T2DM) (i.e. diabetic nephropathy (DN)) has not been well studied in Singapore, a multi-ethnic Asian population. We aimed to determine the prevalence of CKD in adult patients with T2DM. We conducted a cross-sectional study on patients (n = 1861) aged 21 to 89 years with T2DM who had attended the DM centre of a single acute care public hospital or a primary care polyclinic between August 2011 and November 2013. Demographic and clinical data were obtained from patients using a standard questionnaire. Spot urine and fasting blood samples were sent to an accredited hospital laboratory for urinary albumin, serum creatinine, HbA1c and lipid measurement. CKD was defined and classified using the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines and classification. The distribution by risk of adverse CKD outcomes was: low risk, 47%; moderate risk, 27.2%; high risk, 12.8%; and very high risk, 13%. The prevalence of CKD in patients with T2DM was 53%. Variables significantly associated with CKD include neuropathy, blood pressure ≥140/80 mmHg, triglycerides ≥1.7 mmol, body mass index, duration of diabetes, HbA1c ≥8%, age, cardiovascular disease, and proliferative retinopathy. CKD was highly prevalent among patients with T2DM in Singapore. Several risk factors for CKD are well recognised and amenable to intervention. Routine rigorous screening for DN and enhanced programme for global risk factors reduction will be critical to stem the tide of DN.

Foundations of a nursing-sensitive outcome indicator suite for monitoring public patient safety in Western Australia

Summary Background The nursing workforce is critical to improving patient outcomes. Without adequate evidence to guide decision making, restructuring of the nursing workforce to meet increasingly complex patient care needs in the context of registered nurse shortages might fail to produce desired outcomes. Objective To develop a suite of nursing-sensitive outcome indicators for monitoring the safety of multi-day adult medical and surgical patients associated with nurse workloads and nursing workforce models. Design A feasibility study was conducted. Setting Adult acute metropolitan public hospitals in Western Australia. Data sources Patient data for testing the suite were sourced from 2006 to 2010 coded discharge morbidity abstracts. Method Indicator development followed the American Nurses Association (2011) approach: clarifying indicator scope and purpose; determining selection criteria; reviewing the literature for potential indicators; identifying data sources; review by experts; documenting each indicator; and determining baselines. Results The proposed suite comprises 9 indicators pertaining to medical and surgical patients: failure-to-rescue; in-hospital 30-day mortality; average length of stay; hospital-acquired urinary tract infections, sepsis, pneumonia and pressure injuries; falls with injury occurring in hospital; nurse staffing levels (comprising skill mix and nursing care hours per patient day). Conclusions Sufficiently robust administrative data is available to calculate retrospective monthly and annual rates of nursing-sensitive outcomes at unit level and further analysed by ward category for metropolitan patients. Further work is required to pilot test the suite and develop processes for reporting to the Department of Health and hospitals on the impact of nurse staffing and care delivery models on patient outcomes.

An Investigation of Psychology Staffing in Australian Metropolitan Acute Public Hospitals

Psychology is one component of the multidisciplinary services provided to patients in acute public hospitals, with research demonstrating that psychological intervention significantly enhances clinical outcomes for patients across a range of health issues. Despite the increasingly important role that psychologists play in Australian hospitals, there remains a lack of information available about staff levels, discipline structures, and clinical activity for psychological services within acute hospital settings. The most recent Australian data about hospital‐based psychology services was collected 20 years ago. The current study provides updated information from a survey of 15 Australian metropolitan, acute public hospitals: presenting and critically reviewing staffing configurations and models of service delivery. Results suggest that: (a) hospitals employ a highly skilled workforce at a rate of 0.16 full‐time equivalent psychology staff for every 10 hospital beds; (b) psychologists have a viable career pathway within the hospital‐based health sector; (c) role diversity is common, with the primary focus varying as a function of position level; (d) neuropsychology staffing requires urgent attention to address significant delays in access to services; and (e) public hospitals actively contribute to current and future workforce development through supervision, research, and training. The implications of these results for the future of psychological services in Australian healthcare are discussed.

The Impact of Privatization on Efficiency and Productivity: The Case of American Public Hospitals

Public hospitals typically operate in more challenging environments than private hospitals. Research suggests that privatization is one of the strategies that struggling public hospitals adopt to stay competitive. The purpose of this study was to examine whether privatization of public hospitals enhances efficiency and productivity. We used a national sample of non-federal acute care public hospitals in 1997 that was tracked through 2013, resulting in a cohort of 436 hospitals (7,386 hospital-year observations). Privatization was defined as conversion from public to either private not-for-profit or private for-profit status. Efficiency was measured by current assets turnover (CATO), fixed assets turnover (FATO), occupancy rate, full-time equivalent (FTE) employees per occupied bed, and work hours per adjusted patient day. Productivity was measured by case mix adjusted admissions per FTE. We controlled for organizational and market factors. Linear regressions with hospital and year fixed-effects models were used to test the hypotheses. Privatization from public to private status was associated with increased efficiency in terms of its positive associations with CATO (β =0.63) and FATO (β =0.23) and its negative association with FTE employees per occupied bed (β =-0.93) all at (p ≤ 0.001). Privatization was associated with increased productivity (β= 0.83; p ≤ 0.001).

The active aging personal strategies of older adults in Europe: a systematic review protocol of qualitative evidence

REVIEW QUESTION/OBJECTIVE The objectives of this review are to identify the personal strategies related to active aging among older adults in Europe. INCLUSION CRITERIA Types of participants This review will consider studies that include older adults (age over 55 years) who live in Europe. Studies with older adults who suffer cognitive impairment, who are immobilized and unable to perform daily living activities will be excluded. Types of intervention(s)/phenomena of interest This review will consider studies that investigate (any) personal strategies (a process to make change starting with personal research that includes an understanding of one’s life stages, the forces that drive one’s life and plausible events for the current life stage) related to active aging (healthy and active lifestyle, “successful aging”) CONTEXT Europe (considering “some similarity” of health care systems and retirement policies)

Geographic variation of failure-to-rescue in public acute hospitals in New South Wales, Australia.

Despite the wide acceptance of Failure-to-Rescue (FTR) as a patient safety indicator (defined as the deaths among surgical patients with treatable complications), no study has explored the geographic variation of FTR in a large health jurisdiction. Our study aimed to explore the spatiotemporal variations of FTR rates across New South Wales (NSW), Australia. We conducted a population-based study using all admitted surgical patients in public acute hospitals during 2002–2009 in NSW, Australia. We developed a spatiotemporal Poisson model using Integrated Nested Laplace Approximation (INLA) methods in a Bayesian framework to obtain area-specific adjusted relative risk. Local Government Area (LGA) was chosen as the areal unit. LGA-aggregated covariates included age, gender, socio-economic and remoteness index scores, distance between patient residential postcode and the treating hospital, and a quadratic time trend. We studied 4,285,494 elective surgical admissions in 82 acute public hospitals over eight years in NSW. Around 14% of patients who developed at least one of the six FTR-related complications (58,590) died during hospitalization. Of 153 LGAs, patients who lived in 31 LGAs, accommodating 48% of NSW patients at risk, were exposed to an excessive adjusted FTR risk (10% to 50%) compared to the state-average. They were mostly located in state's centre and western Sydney. Thirty LGAs with a lower adjusted FTR risk (10% to 30%), accommodating 8% of patients at risk, were mostly found in the southern parts of NSW and Sydney east and south. There were significant spatiotemporal variations of FTR rates across NSW over an eight-year span. Areas identified with significantly high and low FTR risks provide potential opportunities for policy-makers, clinicians and researchers to learn from the success or failure of adopting the best care for surgical patients and build a self-learning organisation and health system.

Nursing assessment and strategy utilization for falls prevention among medical and orthopedic patients in an acute public hospital setting: A best practice implementation project

BACKGROUND Falls are one of the highest reported adverse events across Australia and much of the world. Implementing targeted, multidisciplinary falls prevention strategies to address risk is considered the cornerstone in falls prevention. OBJECTIVES This project aimed to identify gaps in current practices against international best practice standards and overcome these gaps by identifying barriers and implementing effective practice change with an aim to reduce hospital falls rates. METHOD This project utilized the Joanna Briggs Institute’s Practical Application of Clinical Evidence System and Getting Research into Practice methodology. RESULTS There were numerous gaps identified across the organization, many of which were addressed successfully as part of this process. Follow-up audit revealed increased compliance towards best practice standards compared with baseline, which were sustainable across two audit cycles. This did not however, change the rate of falls on the wards. CONCLUSIONS In conclusion, this was an effective process in identifying best practice gaps throughout the organization and on the wards and implementing effective practice change. However, the best practice literature itself has some gaps that need to be addressed to combat in-hospital falls both nationally and internationally.

Rate of venous thromboembolism among surgical patients in Australian hospitals: a multicentre retrospective cohort study

ObjectivesDespite the burden of venous thromboembolism (VTE) among surgical patients on health systems in Australia, data on VTE incidence and its variation within Australia are lacking. We aim to explore...

Non-Weight-Bearing Status Compromises the Functional Level Up to 1 yr After Hip Fracture Surgery

The aim of this study was to examine the influence of weight-bearing (WB) status after hip fracture surgery on 1-yr functional outcome. This was a prospective cohort study, carried out in a public acute hospital trauma service. The 194 patients (36 men and 158 women), with a mean (SD) age of 81.4 (6.1) yrs, were admitted with a hip fracture within 2009 and were followed for 1 yr thereafter. The influence of postoperative WB status on the 1-yr functional outcome was assessed using the Functional Independence Measure (18-126 points), adjusting for other known factors by multiple linear regression. Seventy-five patients (39%) were not allowed WB for a period of 2-4 wks after surgery. Improved functional outcomes were associated positively with prefracture functional level and having a trochanteric fracture during the first year after fracture (P ≤ 0.01). Non-WB status, age, health status, and cognitive impairment of the patient were associated negatively with the 1-yr functional outcome (P ≤ 0.03). Prefracture functional level and non-WB status were the strongest determinants of functional level (β = 0.599 and -0.204, respectively; P < 0.001). WB status after surgery, in addition to prefracture function, cognitive status, health status, age and fracture type, was found to be an independent predictor of the 1-yr functional outcome in hip fracture patients.

Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion

To understand the changes in the population incidence of inhospital cardiopulmonary arrest (IHCA) and mortality associated with the introduction of rapid response systems (RRSs). Population-based study of 9 221 138 hospital admissions in 82 public acute hospitals in New South Wales, using data linked to a death registry, from 1 Jan 2002 to 31 Dec 2009. Changes in IHCA, IHCA-related mortality, hospital mortality and proportion of IHCA patients surviving to hospital discharge. RRS uptake increased from 32% in 2002 to 74% in 2009. This increase was associated with a 52% decrease in IHCA rate, a 55% decrease in IHCA-related mortality rate, a 23% decrease in hospital mortality rate and a 15% increase in survival to discharge after an IHCA (all P < 0.01). The adjusted absolute reductions in IHCA-related mortality and hospital mortality were 1.49 (95% CI, 1.30-1.68) and 4.05 (95% CI, 3.17-4.76) patients per 1000 admissions, respectively. The decrease in IHCA incidence rate accounted for 95% of the reduction in IHCA-related mortality. In contrast, the increase in IHCA survival accounted for only 5% of the reduction in IHCA-related mortality. During nearly a decade, as RRSs were progressively introduced, there was a coincidental reduction in IHCA, IHCA-related deaths and hospital mortality and an increased survival to hospital discharge after an IHCA. Reduced IHCA incidence, rather than improved postcardiac arrest survival, was the main contributor to the reduction in IHCA mortality.