Author + information
- Julia H. Indik, MD, PhD∗ ()
- ↵∗Address for correspondence:
Dr. Julia H. Indik, Sarver Heart Center, University of Arizona College of Medicine, 1501 N. Campbell Avenue, Tucson, Arizona 85724-5037.
- cardiac arrest
- cardiopulmonary resuscitation (CPR)
- patient safety
- return of spontaneous circulation
It is estimated that each year, 209,000 adults are treated for an in-hospital cardiac arrest (IHCA) (1). To understand how to save these lives requires critical analyses of characteristics related to the patient, responders, and resources available in the environment.
In 2007, Peberdy et al. (2) brought to our attention that survival from an IHCA was more likely if the cardiac arrest occurred during the day or evening of a weekday. They looked at the National Registry of Cardiopulmonary Resuscitation, a prospective multicenter registry that collects Utstein data, for the years of 2000 to 2007, and broke down time periods into weekday days or evenings, weekday nights, and weekends, defined as from 11:00 pm Friday to 7:00 am Monday. They found that the outcomes of return of spontaneous circulation (ROSC), 24-h survival, survival to hospital discharge, and a favorable neurological outcome were best for IHCA that occurred during the day or evening of a weekday. They noticed that patients with a nighttime cardiac arrest were more likely to be unmonitored by telemetry and for their arrest to not be witnessed. There was also a higher proportion of asystolic arrests, raising the question whether asystole was caused by a delay in response. These authors also found interaction effects, such that time of day survival differences were higher for patients arresting in the operating room or post-anesthesia care unit, whereas there was no time of day survival difference in the emergency department or in trauma patients. Of note, this time of day survival difference for IHCA is not unique to adults, but also reported in children (3).
In this issue of the Journal, Ofoma et al. (4) have analyzed the outcomes of 151,071 patients with IHCA expanded for the years 2000 to 2014, with the Get With the Guidelines Resuscitation registry of data from 470 hospitals in the United States. With now 15 years of data they examine the trends in survival comparing 2 groups: patients that arrest during a weekday day-evening, and patients that arrest at any other time (weekday night or weekends). The primary outcome was survival to hospital discharge, with secondary outcomes of acute resuscitation survival (attainment of ROSC for at least 20 min) and post-resuscitation survival (survival to hospital discharge in patients that were successfully resuscitated). They performed analyses adjusting for a large number of variables including patient demographic characteristics, monitored status, witnessed status, use of a hospital-wide cardiac arrest alert system, cardiac arrest rhythms, and drugs and interventions used before the arrest.
Over the course of these 15 years, survival to hospital discharge increased by about 75%, with an unadjusted overall survival to hospital discharge of 13.6% in 2000, and 22.0% in 2014. However, the gap in survival by time of day remains. Over these 15 years, the survival to hospital discharge remained significantly lower if it occurred during the night or on a weekend, compared with a weekday day or evening. Post-resuscitation survival (survival to hospital discharge for resuscitated patients) also showed a highly significant and persistent survival gap by time of day. However, in contrast, the attainment of ROSC did show a significant narrowing of the survival gap between weekday day-evenings and nights or weekends from 2000 to 2014.
There were some interesting changes in cardiac arrest patterns. The relative proportion of asystole as the initial cardiac arrest rhythm declined over time, whereas witnessed status and monitored status increased. These changes were found for both day-evening and night or weekend arrest, and may well have contributed to the overall improved survival. However, at night and on weekends there were still relatively more arrests with asystole, unwitnessed and unmonitored. Is this the answer for the gap? The statistical analysis suggests no, because the survival differences between day-evening and nights or weekends persisted even when adjusted for these and other covariates. Even in the intensive care unit, where patients are continuously monitored and closely watched, there remained a gap between night and day.
What other factors are missing? It may seem obvious that psychomotor skills are better during the daytime, and so staff may not carry out cardiopulmonary resuscitation or be able to analyze the cause of a cardiac arrest as well at night as during the day. However, such difficulties seem to be surmountable in the emergency department (2) and in trauma (2,5), where no survival differences were seen between day and night in those studies. In addition, Ofoma et al. (4) found that there was some narrowing in the gap between day and night for achieving ROSC, suggesting that the obstacles to identifying a cardiac arrest quickly and performing high-quality resuscitation at night can be overcome.
Perhaps looking at weekend days can give a clue for other causes for the persistent gap in survival. Ofoma et al. (4) confirmed what was also reported previously (2), that survival during weekend days was intermediate between nights and weekday day-evenings. On weekends, physicians and other staff that can provide advanced invasive therapies, including coronary angiography and mechanical circulatory support, may not be immediately available on site. Calling someone to come to the hospital to perform a procedure, not only imposes a delay in care, but just may not be done. Without specific protocols that automatically activate certain systems of care post-resuscitation, there may well be suboptimal care provided to the patient resuscitated on the weekend or at night and a reluctance to ask a physician to come to the hospital to perform a procedure.
Next steps should include analyzing the systems of care in hospitals that have the smallest gaps in survival by time of day. Recently, it was reported that among 6 hospitals (6), those hospitals with the highest rates of ROSC for an IHCA incorporated dedicated and structured resuscitation teams and emphasized communication and quality improvement. If an analysis of hospitals with the least gap in survival by time of day can identify system characteristics that can be prospectively collected in the Get With the Guidelines Resuscitation registry, then there will be the means to design and test future system protocols that encompass resuscitation and post-resuscitation care for the IHCA patient.
In summary, Ofoma et al. (4) have shown that clinicians have come a long way in a decade and a half, and it is truly an accomplishment that survival from IHCA has increased substantially. However, a gap still remains for survival for cardiac arrests that occur at night or on a weekend. To close this gap requires the identification of the barriers so that new hospital protocols can be made. Time is of the essence.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Dr. Indik has reported that she has no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
- Mozaffarian D.,
- Benjamin E.J.,
- Go A.S.,
- et al.
- Bhanji F.,
- Topjian A.A.,
- Nadkarni V.M.,
- et al.
- Ofoma U.R.,
- Basnet S.,
- Berger A.,
- Kirchner H.L.,
- Girotra S.
- Nallamothu B.K.,
- Guetterman T.,
- Harrod M.,
- et al.