In-hospital Cardiac Arrest Cases Research Articles

Physiological deterioration prior to in-hospital cardiac arrest: What does the National Early Warning Score-2 miss?

AimTo determine the frequency with which the National Early Warning Score-2 (NEWS-2) fails to detect physiological deterioration preceding in-hospital cardiac arrest (IHCA). MethodsWe conducted a retrospective observational study of all adult patients (age ≥ 18) who had suffered an IHCA between 1st July 2019 and 31st December 2021 in two large acute hospitals located in an urban centre (Nottingham, UK). Clinical observations and case notes were examined for the period leading up to IHCA events to determine if there was evidence of physiological deterioration which warranted an urgent patient assessment, whether NEWS-2 was triggered, and whether an urgent assessment actually took place. ResultsUrgent assessment was indicated in the lead-up to 126/374 (33.7 %) IHCA cases, and NEWS-2 failed to trigger in 20 of these cases (15.9 %). An urgent assessment took place in 89/106 (84.0 %) cases where NEWS-2 was triggered, and 13/20 (65.0 %) cases where NEWS-2 was not triggered, with the difference in proportions being statistically significant (p = 0.048). Half of cases in which NEWS-2 missed a physiological deterioration were related to a new or rising oxygen requirement. ConclusionsA significant proportion of IHCA events are preceded by clinically important abnormalities in vital signs which are not detected by NEWS-2. This may be a causative factor in some failure-to-rescue events.

In-hospital cardiac arrest survival before and after the COVID-19 pandemic: Have higher performing hospitals stayed high-performing?

BackgroundSurvival for in-hospital cardiac arrest (IHCA) has declined since the COVID-19 pandemic. Because the burden of COVID-19 was uneven throughout the U.S., it remains unknown if top-performer hospitals in IHCA survival have remained top-performers since the pandemic. MethodsWithin Get With The Guidelines®-Resuscitation, we identified hospitals with at least 2 years of registry participation pre-pandemic (2017–2019) and post-pandemic (July 2020–2022) and with at least 20 IHCA cases in both periods. Using multivariable hierarchical models with hospital as a random effect and adjusting for patient and arrest characteristics, we calculated risk-standardized survival rates to discharge (RSSR) for IHCA at each hospital during the pre- and post-pandemic periods. We then assessed the correlation between a hospital’s pre-pandemic and post-pandemic RSSR for IHCA, and whether the correlation differed by the proportion of Black or Hispanic IHCA patients at each hospital. ResultsA total of 243 hospitals were included, comprising 122,561 IHCAs (pre-pandemic: 57,601; post-pandemic: 64,960). Pre-pandemic, the mean RSSR was 26.8% (SD, 5.2%) whereas the mean RSSR post-pandemic was 21.7% (SD, 5.5%). There was good correlation between a hospital’s pre- and post-pandemic RSSR: correlation of 0.55. When hospitals were categorized into tertiles based on the proportion of their IHCA patients who were Black or Hispanic, this correlation remained similar: 0.48, 0.68, and 0.45 (interaction P-value: 0.69) for hospitals in the upper, middle and lower tertiles, respectively. ConclusionAlthough the COVID-19 pandemic affected the U.S. unevenly, there was good correlation in a hospital’s performance for IHCA survival before and after the pandemic, even at hospitals caring for a larger proportion of Black and Hispanic patients. Future studies are needed to understand what characteristics of high-performing hospitals pre-pandemic allowed many to continue to excel in the post-pandemic period.

Aetiology and predictors of outcome in non-shockable in-hospital cardiac arrest: A retrospective cohort study from the Swedish Registry for Cardiopulmonary Resuscitation.

Non-shockable in-hospital cardiac arrest (IHCA) is a condition with diverse aetiology, predictive factors, and outcome. This study aimed to compare IHCA with initial asystole or pulseless electrical activity (PEA), focusing specifically on their aetiologies and the significance of predictive factors. Using the Swedish Registry of Cardiopulmonary Resuscitation, adult non-shockable IHCA cases from 2018 to 2022 (n = 5788) were analysed. Exposure was initial rhythm, while survival to hospital discharge was the primary outcome. A random forest model with 28 variables was used to generate permutation-based variable importance for outcome prediction. Overall, 60% of patients (n = 3486) were male and the median age was 75 years (IQR 67-81). The most frequent arrest location (46%) was on general wards. Comorbidities were present in 79% of cases and the most prevalent comorbidity was heart failure (33%). Initial rhythm was PEA in 47% (n = 2702) of patients, and asystole in 53% (n = 3086). The most frequent aetiologies in both PEA and asystole were cardiac ischemia (24% vs. 19%, absolute difference [AD]: 5.4%; 95% confidence interval [CI] 3.0% to 7.7%), and respiratory failure (14% vs. 13%, no significant difference). Survival was higher in asystole (24%) than in PEA (17%) (AD: 7.3%; 95% CI 5.2% to 9.4%). Cardiopulmonary resuscitation (CPR) durations were longer in PEA, 18 vs 15 min (AD 4.9 min, 95% CI 4.0-5.9 min). The duration of CPR was the single most important predictor of survival across all subgroup and sensitivity analyses. Aetiology ranked as the second most important predictor in most analyses, except in the asystole subgroup where responsiveness at cardiac arrest team arrival took precedence. In this nationwide registry study of non-shockable IHCA comparing asystole to PEA, cardiac ischemia and respiratory failure were the predominant aetiologies. Duration of CPR was the most important predictor of survival, followed by aetiology. Asystole was associated with higher survival compared to PEA, possibly due to shorter CPR durations and a larger proportion of reversible aetiologies.

Epidemiologic investigation of cardiac arrest and current research status on its risk factors analysis

Cardiac arrest most commonly occurs outside of the hospital, known as out-of-hospital cardiac arrest (OHCA), and is an important global health problem. Approximately 40% of cardiac arrest has no clear cause. Hereditary arrhythmias and cardiomyopathies factors contribute to cardiac arrest. The identification of genetic factors for cardiac arrest after its occurrence is of great value not only for the individual, but also for relatives who may be at risk for the disease in their family. In the United States, there are over 350 000 cases of OHCA and over 200 000 cases of in-hospital cardiac arrest (IHCA) each year, and in Western Europe, cardiac arrest accounts for 15%-20% of all adult natural deaths and 50% of all cardiovascular deaths. In order to reduce the burden caused by cardiac arrest within society, it is essential to further understand its etiological factors, such as incidence in different regions, risk factors, and populations at higher risk. For each individual, cardiac arrest is the result of a complex interaction of genetic and acquired factors. Understanding the complex interplay of pathogenic factors in cardiac arrest and the development of individualized prevention and treatment approaches requires the collection of clinical data from cardiac arrest populations and multimodal analysis in order to identify epidemiological features and risk factors for cardiac arrest. Recently, cardiac arrest-related data are being collected and integrated in Europe in different regions and populations. As a result of the commitment to the creation of large datasets of clinical information on cardiac arrest populations, the knowledge of the pathology of cardiac arrest pathogenesis as well as risk factors is steadily increasing. This article reviews the epidemiologic data of cardiac arrest in recent years and the associated risk factors, thus providing ideas for developing better strategies for the prevention and treatment of cardiac arrest.

Does a Transition to Single-Occupancy Patient Rooms Affect the Incidence and Outcome of In-Hospital Cardiac Arrests?

It is proposed that patients in single-occupancy patient rooms (SPRs) carry a risk of less surveillance by nursing and medical staff and that resuscitation teams need longer to arrive in case of in-hospital cardiac arrest (IHCA). Higher incidences of IHCA and worse outcomes after cardiopulmonary resuscitation (CPR) may be the result. Our study examines whether there is a difference in incidence and outcomes of IHCA before and after the transition from a hospital with multibedded rooms to solely SPRs. In this prospective observational study in a Dutch university hospital, as a part of the Resuscitation Outcomes in the Netherlands study, we reviewed all cases of IHCA on general adult wards in a period of 16.5 months before to 16.5 months after the transition to SPRs. During the study period, 102 CPR attempts were performed: 51 in the former hospital and 51 in the new hospital. Median time between last-seen-well and start basic life support did not differ significantly, nor did median time to arrival of the CPR team. Survival rates to hospital discharge were 30.0% versus 29.4% of resuscitated patients (p = 1.00), with comparable neurological outcomes: 86.7% of discharged patients in the new hospital had Cerebral Performance Category 1 (good cerebral performance) versus 46.7% in the former hospital (p = .067). When corrected for telemetry monitoring, these differences were still nonsignificant. The transition to a 100% SPR hospital had no negative impact on incidence, survival rates, and neurological outcomes of IHCAs on general adult wards.

All Else Being Equal: Examining Treatment Bias and Stereotypes Based on Patient Ethnicity and Socioeconomic Status With In-Hospital Cardiac Arrest Clinical Vignettes

BackgroundResearch on ethnic and socioeconomic treatment differences following in-hospital cardiac arrest (IHCA) largely draws on register data. Due to the correlational nature of such data, it cannot be concluded whether detected differences reflect treatment bias/discrimination – whereby otherwise identical patients are treated differently solely due to sociodemographic factors. To be able to establish discrimination, experimental research is needed. ObjectiveThe primary aim of this experimental study was to examine whether simulated IHCA patients receive different treatment recommendations based on ethnicity and socioeconomic status (SES), holding all other factors (e.g., health status) constant. Another aim was to examine health care professionals’ (HCP) stereotypical beliefs about these groups. MethodsHCP (N = 235) working in acute care made anonymous treatment recommendations while reading IHCA clinical vignettes wherein the patient's ethnicity (Swedish vs. Middle Eastern) and SES had been manipulated. Afterwards they estimated to what extent hospital staff associate these patient groups with certain traits (stereotypes). ResultsNo significant differences in treatment recommendations for Swedish versus Middle Eastern or high versus low SES patients were found. Reported stereotypes about Middle Eastern patients were uniformly negative. SES-related stereotypes, however, were mixed. High SES patients were believed to be more competent (e.g., respected), but less warm (e.g., friendly) than low SES patients. ConclusionsSwedish HCP do not seem to discriminate against patients with Middle Eastern or low SES backgrounds when recommending treatment for simulated IHCA cases, despite the existence of negative stereotypes about these groups. Implications for health care equality and quality are discussed.

Abstract 220: The Prediction Of Pulseless Electrical Activity Evolution During In-hospital Cardiac Arrest Using Machine Learning

Background: Pulseless electrical activity (PEA) is the most common rhythm during in-hospital cardiac arrest (IHCA) with a prevalence around 50%. Knowing the prognosis of PEA evolution towards return of spontaneous circulation (ROSC) could help optimizing both resuscitation maneuvers and pharmacological therapy. The aim of this study was to develop an automatic method to predict the evolution of PEA during resuscitation based on the ECG-waveform. Materials and Methods: The dataset consists of 164 IHCA cases recorded by St. Olav University Hospital (Norway), Hospital of the University of Pennsylvania (USA) and Penn Presbyterian Medical Center (USA). ROSC was verified in 108 cases of the patients by physicians and bioengineers based on episode waveforms and clinical data. PEA segments of 5 sec were extracted from the last 10 min before ROSC or the end of resuscitation therapy. Three machine learning models were designed for segment binary classification based on an SVM (Gaussian) model using: 1) ECG-waveform features (9); 2) QRS-features (8); and 3) both ECG-waveform and QRS-features (17). Ten-fold cross validation was applied to train and test the models, and the performance was given in terms of area under the curve (AUC), sensitivity (Se) to correctly detect cases evolving to ROSC, specificity (Sp) and balanced accuracy (BAC). Results: A total of 780 segments were extracted (472 with ROSC). The median (IQR) for the models with the best feature combination are shown in the Table. The most important ECG-waveform features are associated to the ECG spectral distribution. QRS features that showed relevant information about the evolution of PEA were heart rate median and standard deviation, and QRS width, slope and amplitude. Conclusions: ROSC/no ROSC prediction of PEA segments is feasible using ECG signal information. The combination of ECG-waveform and QRS features enhances performance of predictive model.

Multicenter validation of a deep-learning-based pediatric early-warning system for prediction of deterioration events.

Early recognition of deterioration events is crucial to improve clinical outcomes. For this purpose, we developed a deep-learning-based pediatric early-warning system (pDEWS) and aimed to validate its clinical performance. This is a retrospective multicenter cohort study including five tertiary-care academic children's hospitals. All pediatric patients younger than 19 years admitted to the general ward from January 2019 to December 2019 were included. Using patient electronic medical records, we evaluated the clinical performance of the pDEWS for identifying deterioration events defined as in-hospital cardiac arrest (IHCA) and unexpected general ward-to-pediatric intensive care unit transfer (UIT) within 24 hours before event occurrence. We also compared pDEWS performance to those of the modified pediatric early-warning score (PEWS) and prediction models using logistic regression (LR) and random forest (RF). The study population consisted of 28,758 patients with 34 cases of IHCA and 291 cases of UIT. pDEWS showed better performance for predicting deterioration events with a larger area under the receiver operating characteristic curve, fewer false alarms, a lower mean alarm count per day, and a smaller number of cases needed to examine than the modified PEWS, LR, or RF models regardless of site, event occurrence time, age group, or sex. The pDEWS outperformed modified PEWS, LR, and RF models for early and accurate prediction of deterioration events regardless of clinical situation. This study demonstrated the potential of pDEWS as an efficient screening tool for efferent operation of rapid response teams.

Trends in survival after cardiac arrest: a Swedish nationwide study over 30 years.

Trends in characteristics, management, and survival in out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) were studied in the Swedish Cardiopulmonary Resuscitation Registry (SCRR). The SCRR was used to study 106 296 cases of OHCA (1990-2020) and 30 032 cases of IHCA (2004-20) in whom resuscitation was attempted. In OHCA, survival increased from 5.7% in 1990 to 10.1% in 2011 and remained unchanged thereafter. Odds ratios [ORs, 95% confidence interval (CI)] for survival in 2017-20 vs. 1990-93 were 2.17 (1.93-2.43) overall, 2.36 (2.07-2.71) for men, and 1.67 (1.34-2.10) for women. Survival increased for all aetiologies, except trauma, suffocation, and drowning. OR for cardiac aetiology in 2017-20 vs. 1990-93 was 0.45 (0.42-0.48). Bystander cardiopulmonary resuscitation increased from 30.9% to 82.2%. Shockable rhythm decreased from 39.5% in 1990 to 17.4% in 2020. Use of targeted temperature management decreased from 42.1% (2010) to 18.2% (2020). In IHCA, OR for survival in 2017-20 vs. 2004-07 was 1.18 (1.06-1.31), showing a non-linear trend with probability of survival increasing by 46.6% during 2011-20. Myocardial ischaemia or infarction as aetiology decreased during 2004-20 from 67.4% to 28.3% [OR 0.30 (0.27-0.34)]. Shockable rhythm decreased from 37.4% to 23.0% [OR 0.57 (0.51-0.64)]. Approximately 90% of survivors (IHCA and OHCA) had no or mild neurological sequelae. Survival increased 2.2-fold in OHCA during 1990-2020 but without any improvement in the final decade, and 1.2-fold in IHCA during 2004-20, with rapid improvement the last decade. Cardiac aetiology and shockable rhythms were halved. Neurological outcome has not improved.

Incidence and outcomes of in-hospital cardiac arrest in Japan 2011\u20132017: a nationwide inpatient database study

BackgroundAlthough numerous studies have investigated out-of-hospital cardiac arrest, few studies have been conducted on in-hospital cardiac arrest (IHCA). Knowledge of the nationwide epidemiology of IHCA in Japan, with its super-aging society, is important to understand the current situation of IHCA and to establish evidenced-based medicine in the future. The present study aimed to determine the incidence and outcomes of IHCA and their trends in Japan.MethodsThis observational cohort study was performed using a national administrative inpatient database for more than 1600 acute-care hospitals covering about 50% of all acute-care hospital beds in Japan from April 2011 to March 2018. We defined cardiac arrest patients who received cardiopulmonary resuscitation (chest compression) during hospitalization as IHCA. We excluded out-of-hospital cardiac arrest patients from the source population. The incidence of IHCA per 1000 hospital admissions and survival to discharge rate was reported with trend analyses by calendar year 2011–2017.ResultsAmong 53,871,101 hospitalized patients without out-of-hospital cardiac arrest patients in 1626 hospitals, 2,136,038 (4.0%) had cardiac arrest. Of them, 274,664 (12.9%) received cardiopulmonary resuscitation at least once during hospitalization and were identified as IHCA, and 1,861,374 (87.1%) did not receive cardiopulmonary resuscitation. The incidence of IHCA per 1000 hospital admissions was 5.1, with a significant decreasing trend from 6.1 in 2011 to 4.6 in 2017 (P for trend = 0.033). Our estimated incidence can be translated to approximately 87,000 IHCA cases in Japan each year. The percentage of IHCA patients among cardiac arrest patients was 12.9%, with a significant decreasing trend from 14.0% in 2011 to 12.2% in 2017 (P for trend = 0.006). The overall rate of survival to discharge was 12.7%, with a significant increasing trend from 10.5% in 2011 to 14.0% in 2017 (P for trend < 0.001).ConclusionsWe found substantial associations between mortality and loss of health and IHCA in Japan. The incidence of IHCA showed a decreasing trend over time, the percentage of treated cardiac arrest patients also had a decreasing trend, and the overall survival to discharge rate improved over time.

Role of a rapid response system and code status discussion as determinants of prognosis for critical inpatients: An observational study in a Japanese urban hospital.

Rapid response systems (RRS) have been introduced worldwide to reduce unpredicted in-hospital cardiac arrest (IHCA) and in-hospital mortality. The role of advance care planning (ACP) in the management of critical patients has not yet been fully determined in Japan.We retrospectively assessed the characteristics of all inpatients with unpredicted IHCA in our hospital between 2016 and 2018. Yearly changes in the number of RRS activations and the incidence of unpredicted IHCA with or without code status discussion were evaluated from 2014 to 2018. Hospital standardized mortality ratios were assessed from the data reported in the annual reports by the National Hospital Organization.A total of 81 patients (age: 70.9 ± 13.3 years) suffered an unpredicted IHCA and had multiple background diseases, including heart disease (75.3%), chronic kidney disease (25.9%), and postoperative status (cardiovascular surgery, 18.5%). Most of the patients manifested non-shockable rhythms (69.1%); survival to hospital discharge rate was markedly lower than that with shockable rhythms (26.8% vs 72.0%, P < .001). The hospital standardized mortality ratios was maintained nearly constant at approximately 50.0% for 3 consecutive years. The number of cases of RRS activation markedly increased from 75 in 2014 to 274 patients in 2018; conversely, the number of unpredicted IHCA cases was reduced from 40 in 2014 to 18 in 2018 (P < .001). Considering the data obtained in 2014 and 2015 as references, the RRS led to a reduction in the relative risk of unpredicted IHCA from 2016 to 2018 (ie, 0.618, 95% confidence interval 0.453–0.843). The reduction in unpredicted IHCA was attributed partly to the increased number of patients who had discussed the code status, and a significant correlation was observed between these parameters (R2 = 0.992, P < .001). The reduction in the number of patients with end-stage disease, including congestive heart failure and chronic renal failure, paralleled the incidence of unpredicted IHCA.Both RRS and ACP reduced the incidence of unpredicted IHCA; RRS prevents progression to unpredicted IHCA, whereas ACP decreases the number of patients with no code status discussion and thus potentially reducing the patient subgroup progressing to an unpredicted IHCA.

Epidemiology, etiology, and outcomes of in-hospital cardiac arrest in Lebanon.

BACKGROUNDIn-hospital cardiac arrest (IHCA) constitutes a significant cause of morbidity and mortality. As data is scarce in the Middle East and Lebanon, we devised this study to shed some light on it to better inform both hospitals and policymakers about the magnitude and quality of IHCA care in Lebanon.METHODSWe analyzed retrospective data from 680 IHCA events at the American University of Beirut Medical Center between July 1, 2016 and May 2, 2019. Sociodemographic variables included age and sex, in addition to the comorbidities listed in the Charlson comorbidity index. IHCA event variables were day, event location, time from activation to arrival, initial cardiac rhythm, and the total number of IHCA events. We also looked at the months and years. We considered the return of spontaneous circulation (ROSC) and survival to discharge (StD) to be our outcomes of interest.RESULTSThe incidence of IHCA was 6.58 per 1,000 hospital admissions (95% CI: 6.09−7.08). Non-shockable rhythms were 90.7% of IHCAs. Most IHCA cases occurred in the closed units (87.9%) (intensive care unit, respiratory care unit, neurology care unit, and cardiology care unit) and on weekdays (76.5%). ROSC followed more than half the IHCA events (56%). However, only 5.4% of IHCA events achieved StD. Both ROSC and StD were higher in cases with a shockable rhythm. Survival outcomes were not significantly different between day, evening, and nightshifts. ROSC was not significantly different between weekdays and weekends; however, StD was higher in events that happened during weekdays than weekends (6.7%vs. 1.9%, P = 0.002). CONCLUSIONSThe incidence of IHCA was high, and its outcomes were lower compared to other developed countries. Survival outcomes were better for patients who had a shockable rhythm and were similar between the time of day and days of the week. These findings may help inform hospitals and policymakers about the magnitude and quality of IHCA care in Lebanon.

Effects of COVID-19 on in-hospital cardiac arrest: incidence, causes, and outcome \u2013 a retrospective cohort study

BackgroundSevere acute respiratory syndrome coronavirus-2 (SARS-CoV-2), an emerging virus, has caused a global pandemic. Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has led to high hospitalization rates worldwide. Little is known about the occurrence of in-hospital cardiac arrest (IHCA) and high mortality rates have been proposed. The aim of this study was to investigate the incidence, characteristics and outcome of IHCA during the pandemic in comparison to an earlier period.MethodsThis was a retrospective analysis of data prospectively recorded during 3-month-periods 2019 and 2020 at the University Medical Centre Hamburg-Eppendorf (Germany). All consecutive adult patients with IHCA were included. Clinical parameters, neurological outcomes and organ failure/support were assessed.ResultsDuring the study period hospital admissions declined from 18,262 (2019) to 13,994 (2020) (− 23%). The IHCA incidence increased from 4.6 (2019: 84 IHCA cases) to 6.6 (2020: 93 IHCA cases)/1000 hospital admissions. Median stay before IHCA was 4 (1–9) days. Demographic characteristics were comparable in both periods. IHCA location shifted towards the ICU (56% vs 37%, p < 0.01); shockable rhythm (VT/VF) (18% vs 29%, p = 0.05) and defibrillation were more frequent in the pandemic period (20% vs 35%, p < 0.05). Resuscitation times, rates of ROSC and post-CA characteristics were comparable in both periods. The severity of illness (SAPS II/SOFA), frequency of mechanical ventilation and frequency of vasopressor therapy after IHCA were higher during the 2020 period. Overall, 43 patients (12 with & 31 without COVID-19), presented with respiratory failure at the time of IHCA. The Horowitz index and resuscitation time were significantly lower in patients with COVID-19 (each p < 0.01). Favourable outcomes were observed in 42 and 10% of patients with and without COVID-19-related respiratory failure, respectively.ConclusionHospital admissions declined during the pandemic, but a higher incidence of IHCA was observed. IHCA in patients with COVID-19 was a common finding. Compared to patients with non-COVID-19-related respiratory failure, the outcome was improved.

Cardiac arrest in COVID-19: characteristics and outcomes of in- and out-of-hospital cardiac arrest. A report from the Swedish Registry for Cardiopulmonary Resuscitation.

AimTo study the characteristics and outcome among cardiac arrest cases with COVID-19 and differences between the pre-pandemic and the pandemic period in out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA).Method and resultsWe included all patients reported to the Swedish Registry for Cardiopulmonary Resuscitation from 1 January to 20 July 2020. We defined 16 March 2020 as the start of the pandemic. We assessed overall and 30-day mortality using Cox regression and logistic regression, respectively. We studied 1946 cases of OHCA and 1080 cases of IHCA during the entire period. During the pandemic, 88 (10.0%) of OHCAs and 72 (16.1%) of IHCAs had ongoing COVID-19. With regards to OHCA during the pandemic, the odds ratio for 30-day mortality in COVID-19-positive cases, compared with COVID-19-negative cases, was 3.40 [95% confidence interval (CI) 1.31–11.64]; the corresponding hazard ratio was 1.45 (95% CI 1.13–1.85). Adjusted 30-day survival was 4.7% for patients with COVID-19, 9.8% for patients without COVID-19, and 7.6% in the pre-pandemic period. With regards to IHCA during the pandemic, the odds ratio for COVID-19-positive cases, compared with COVID-19-negative cases, was 2.27 (95% CI 1.27–4.24); the corresponding hazard ratio was 1.48 (95% CI 1.09–2.01). Adjusted 30-day survival was 23.1% in COVID-19-positive cases, 39.5% in patients without COVID-19, and 36.4% in the pre-pandemic period.ConclusionDuring the pandemic phase, COVID-19 was involved in at least 10% of all OHCAs and 16% of IHCAs, and, among COVID-19 cases, 30-day mortality was increased 3.4-fold in OHCA and 2.3-fold in IHCA.

Clinical characteristics and outcomes of in-hospital cardiac arrest among patients with and without COVID-19

AimsTo define outcomes of patients with COVID-19 compared to patients without COVID-19 suffering in-hospital cardiac arrest (IHCA). Materials and methodsWe performed a single-center retrospective study of IHCA cases. Patients with COVID-19 were compared to consecutive patients without COVID-19 from the prior year. Return of spontaneous circulation (ROSC), 30-day survival, and cerebral performance category (CPC) at 30-days were assessed. ResultsFifty-five patients with COVID-19 suffering IHCA were identified and compared to 55 consecutive IHCA patients in 2019. The COVID-19 cohort was more likely to require vasoactive agents (67.3% v 32.7%, p=0.001), invasive mechanical ventilation (76.4% v 23.6%, p<0.001), renal replacement therapy (18.2% v 3.6%, p=0.029) and intensive care unit care (83.6% v 50.9%, p=0.001) prior to IHCA. Patients with COVID-19 had shorter CPR duration (10min v 22min, p=0.002). ROSC (38.2% v 49.1%, p=0.336) and 30-day survival (20% v 32.7%, p=0.194) did not differ. A 30-day cerebral performance category of 1 or 2 was more common among non-COVID patients (27.3% v 9.1%, p=0.048). ConclusionsReturn of spontaneous circulation and 30-day survival were similar between IHCA patients with and without COVID-19. Compared to previously published data, we report greater ROSC and 30-day survival after IHCA in COVID-19.

10-year trend analysis of in-hospital cardiac arrest: 2008–2017 United State hospitalizations

Abstract Introduction In-hospital cardiac arrest (IHCA) survival trends have not been well reported in recent years. Whether the implementation of the new 2015 AHA guideline affects the survival of IHCA is largely unknown. Our study aims to provide an updated analysis of the trends of IHCA among the hospitals in the United States Method Using United States National Inpatient Sample Database 2008–2017, the cohort was generated with patients age above 18 who received Cardiopulmonary resuscitation during Hospitalization. Hospitalization with a principle diagnosis of cardiac arrest or ventricular fibrillation/ventricular tachycardia were excluded as outside hospital cardiac arrest. Demographic features, baseline characteristic as well as hospital outcomes were described. Trend analysis was performed using a multivariate model adjusted for age, sex, and comorbidities score. Results From 2008 to 2017, the cases of In-hospital cardiac arrest (IHCA) has steadily increased from 96,771 to 106,320. This trend was accompanied by a decline in age from (67.48±0.30 to 65.78±0.13, Ptrend &amp;lt;0.001) but increase in comorbidity score (from 2.44±0.27 to 3.47±0.21, Ptrend &amp;lt;0.001). It is noted that the mortality rate has been steadily declining since 2008 (from 74.01% to 68.68%, Ptrend &amp;lt;0.001)), although no significant changes before or after 2015 were noted (from 68.90 to 68.68, P&amp;gt;0.05). Length of stay has decreased from an average of 9.06± days to 8.76±0.13 days at the cost of increased health care costs (from 30.78 to 37.40 thousand dollar P&amp;lt;0.001 adjusted for inflation rate). Conclusion The survival rate of In-hospital cardiac arrest has increased from 2008 to 2017 despite increased comorbidity burden. The length of stays has decreased at the cost of an increase in health costs. Funding Acknowledgement Type of funding source: None

Association Between Hospital Debriefing Practices With Adherence to Resuscitation Process Measures and Outcomes for In-Hospital Cardiac Arrest.

Background Identifying actionable resuscitation practices that vary across hospitals could improve adherence to process measures or outcomes after in-hospital cardiac arrest (IHCA). We sought to examine whether hospital debriefing frequency after IHCA varies across hospitals and whether hospitals which routinely perform debriefing have higher rates of process-of-care compliance or survival. Methods We conducted a nationwide survey of hospital resuscitation practices in April of 2018, which were then linked to data from the Get With The Guidelines-Resuscitation national registry for IHCA. Hospitals were categorized according to their reported frequency of debriefing immediately after IHCA; rarely (0%-20% of all IHCA cases), occasionally (21%-80%), and frequently (81%-100%). Hospital-level rates of timely defibrillation (≤2 minutes), epinephrine administration (≤5 minutes), survival to discharge, return of spontaneous circulation, and neurologically intact survival were comparted for patients with IHCA from 2015 to 2017. Results Overall, there were 193 hospitals comprising 44 477 IHCA events. Mean patient age was 65±16, 41% were females, and 68% were of White race. Across hospitals, 84 (43.5%) rarely performed debriefings immediately after an IHCA, 82 (42.5%) performed debriefing sessions occasionally, and 27 (14.0%) performed debriefing frequently. There was no association between higher reported debriefing frequency and hospital rates of timely defibrillation and epinephrine administration. Mean hospital rates of risk-standardized survival to discharge were similar across debriefing frequency groups (rarely 25.6%; occasionally 26.0%; frequently 25.2%, P=0.72), as were hospital rates of risk-adjusted return of spontaneous circulation (rarely 72.2%; occasionally 73.0%; frequently 70.0%, P=0.06) and neurologically intact survival (rarely 21.9%, occasionally 22.2%, frequently 21.1%, P=0.75). Conclusions In a large contemporary nationwide quality improvement registry, hospitals varied widely in how often they conducted debriefings immediately after IHCA. However, hospital debriefing frequency was not associated with better adherence to timely delivery of epinephrine or defibrillation or higher rates of IHCA survival.

Abstract 461: Evaluation of the Impact of Additional Structured Cardiac Arrest Training on Internal Medicine Residents in a Community Hospital

Introduction: There are approximately 200,000 cases of in-hospital cardiac arrest (IHCA) annually in the United States. Of these cases, only 40-50% achieve return of spontaneous circulation (ROSC) and only 20-30% are discharged. Though most hospital staff are trained in cardiac arrest resuscitation, a significant disparity in resuscitation has been noted between different hospital settings. We thus instituted additional structured cardiac arrest training in an Internal Medicine residency program, to supplement the biennial advanced cardiac life support (ACLS) training. Hypothesis: We hypothesized that institution of a dedicated structured cardiac arrest team (code team) in addition to monthly training for those on the team, would improve the confidence, skills, and leadership level, of residents at managing an IHCA situation. Methods: A structured code team with specific roles for each resident was instituted in a New York City-based community hospital. Training was guided by audio-visual lectures and then reinforced by performing mock cardiac arrest drills. Resident assessments were done pre and post-training through an anonymous standardized questionnaire. Summative measures of mean confidence, mean ACLS skills, and leadership were evaluated. Uni and bivariate analysis, and T-tests for statistical significance were performed using STATA 15 software. Results: Our sample of 32 residents showed an increase in mean learning scores across all the three domains. Confidence scores increased from 7.23 to 8.44, ACLS skills increased from 7.40 to 8.57 and leadership scores increased from 6.56 to 7.88. Paired T-tests demonstrated high significance (P&lt;0.000). Conclusion: This study demonstrates the effectiveness of additional structured cardiac arrest training on confidence, skills, and leadership of resident physicians in an Internal Medicine program. The next phase of this study will be to re-evaluate knowledge and confidence at 3 and 6 months after training.

Abstract 18: Trends in Median CPR Duration Over Time in Patients With and Without Return of Spontaneous Circulation

Introduction: Survival after in-hospital cardiac arrest (IHCA) is increasing. In the Get-With-The-Guidelines-Resuscitation (GWTG-R) registry, longer median CPR duration in patients not achieving ROSC is associated with higher survival rates at the hospital level. We analyzed trends over time in median CPR duration by hospital in patients who achieved ROSC and those who did not, and stratified this analysis by age, gender and race. Methods: We included adult IHCA cases in GWTG-R from 2001-2017, excluding data from a given hospital and year if fewer than 5 eligible arrests were recorded. A nonparametric test for trend was done to evaluate median CPR duration over time in those with and without ROSC, in all patients and in groups stratified by age (&lt;60, 61-80 and &gt;80 years), gender, and race (white and black). Linear regression was done to evaluate the amount of change per year. Association with survival was tested using Pearsons correlation. Results: Of 359,107 IHCA events, 31,189 were excluded, leaving 327,918 for analysis. Over time, there was a significant increase in median CPR duration in patients who did not achieve ROSC, and a decrease in those who did attain ROSC.(Fig.) These trends persisted when stratified by gender, race and age. Each year was associated with a decrease in median CPR duration of 0.37 min (95% CI -0.41 to -0.33 min) in those with ROSC and an increase of 0.29 min (95% CI 0.25 to 0.33 min) in those without. There was a small but significant correlation between median CPR duration in those without ROSC and adjusted survival by hospital over time (r=0.224, p&lt;0.0001). Conclusions: In the GWTG-R registry, median duration of CPR is decreasing over time in patients achieving ROSC, but increasing in those not achieving ROSC. The increasing trend in CPR duration in those without ROSC correlates positively with the trend in survival. Whether the increase in median CPR duration in those without ROSC is contributing causally to improvements in survival warrants further study.

P083: Innovative use of AED by RNs and RTs during in-hospital cardiac arrest (Phase III)

Introduction: In-hospital cardiac arrest (IHCA) most commonly occurs in non-monitored areas, where we observed a 10min delay before defibrillation (Phase I). Nurses (RNs) and respiratory therapists (RTs) cannot legally use Automated External Defibrillators (AEDs) during IHCA without a medical directive. We sought to evaluate IHCA outcomes following usual implementation (Phase II) vs. a Theory-Based educational program (Phase III) allowing RNs and RTs to use AEDs during IHCA. Methods: We completed a pragmatic before-after study of consecutive IHCA. We used ICD-10 codes to identify potentially eligible cases and included IHCA cases for which resuscitation was attempted. We obtained consensus on all data definitions before initiation of standardized-piloted data extraction by trained investigators. Phase I (Jan.2012-Aug.2013) consisted of baseline data. We implemented the AED medical directive in Phase II (Sept.2013-Aug.2016) using usual implementation strategies. In Phase III (Sept.2016-Dec.2017) we added an educational video informed by key constructs from a Theory of Planned Behavior survey. We report univariate comparisons of Utstein IHCA outcomes using 95% confidence intervals (CI). Results: There were 753 IHCA for which resuscitation was attempted with the following similar characteristics (Phase I n = 195; II n = 372; III n = 186): median age 68, 60.0% male, 79.3% witnessed, 29.7% non-monitored medical ward, 23.9% cardiac cause, 47.9% initial rhythm of pulseless electrical activity and 27.2% ventricular fibrillation/tachycardia (VF/VT). Comparing Phases I, II and III: an AED was used 0 times (0.0%), 21 times (5.6%), 15 times (8.1%); time to 1st rhythm analysis was 6min, 3min, 1min; and time to 1st shock was 10min, 10min and 7min. Comparing Phases I and III: time to 1st shock decreased by 3min (95%CI -7; 1), sustained ROSC increased from 29.7% to 33.3% (AD3.6%; 95%CI -10.8; 17.8), and survival to discharge increased from 24.6% to 25.8% (AD1.2%; 95%CI -7.5; 9.9). In the VF/VT subgroup, time to first shock decreased from 9 to 3 min (AD-6min; 95%CI -12; 0) and survival increased from 23.1% to 38.7% (AD15.6%; 95%CI -4.3; 35.4). Conclusion: The implementation of a medical directive allowing for AED use by RNs and RRTs successfully improved key outcomes for IHCA victims, particularly following the Theory-Based education video. The expansion of this project to other hospitals and health care professionals could significantly impact survival for VF/VT patients.