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Survival decreases in in-hospital cardiac arrest during off-hours
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Despite an overall improvement in survival, in-hospital cardiac arrest mortality was higher during off-hours, according to a study published in the Journal of the American College of Cardiology.
“Nearly 50% of in-hospital cardiac arrests take place during ‘off-hours,’” Uchenna R. Ofoma, MD, MS, associate of critical care medicine and director of critical care fellowship research at Geisinger Health System in Danville, Pennsylvania, and assistant professor of medicine at Temple University, said in a press release. “By determining how survival has changed in recent years, we may be able to identify opportunities for quality improvement efforts. If we can improve survival for cardiac arrests that occur during off-hours, it could impact a substantial number of patients.”
Get With the Guidelines data
Researchers analyzed data from 151,071 patients (mean age, 66 years; 42% women) from the Get With the Guidelines-Resuscitation registry who had an in-hospital cardiac arrest in 470 hospitals. Exclusion criteria included those with cardiac arrest outside of a hospital ward or ICU and patients with an implantable cardioverter defibrillator.
Patient data were reviewed, including comorbidities, demographics, pre-existing medical conditions, cardiac arrest characteristics and interventions in place before the cardiac arrest.
On-hours was defined as the time between 7 a.m. and 10:59 p.m. Monday to Friday, and off-hours was 11 p.m. to 6:59 a.m. Monday to Friday or weekends.
The primary outcome of interest was survival to hospital discharge. Secondary outcomes of interest were defined as acute resuscitation survival, which was the return of spontaneous circulation for at least 20 minutes after the initial arrest, and post-resuscitation survival, which was survival to hospital discharge in those who had their spontaneous circulation returned.
In-hospital cardiac arrest during off-hours occurred in 52.4% of patients.
Cardiac arrest survival
Risk-adjusted survival increased over time in the off-hours group, from 11.9% in 2000 to 21.9% in 2014 (P for trend < .001). This was also seen in the on-hours group, from 16% in 2000 to 25.2% in 2014 (P for trend < .001). There was no significant difference in survival between the two groups on an absolute (P for trend = .75) and relative scale (P for interaction = .0592).
After adjusting for risk, acute resuscitation survival increased in the on-hours group from 2000 (56.1%) to 2014 (71%; P for trend < .001). This also increased in the off-hours group (46.9% to 68.2%; P for trend < .001). Over time, the difference between the two groups narrowed on an absolute (P = .02) and relative scale (P for interaction = .0005).
As post-resuscitation survival increased in the on-hours (26.5% to 36%; P for trend < .001) and off-hours groups (24.5% to 33.5%; P for trend < .001), differences persisted between both groups.
“Poor survival during nights and weekends is likely caused by a multitude of factors,” Ofoma and colleagues wrote. “Changes in hospital staffing patterns during nights and weekends are common, both numerically and in terms of expertise of available physicians. Moreover, physicians who work during nights and weekends also provide coverage to patients they may be less familiar with. Likewise, nurse-to-patient ratios are also lower during off-hours because of fewer admissions and discharges. Finally, the impact of shift work particularly during nighttime has been shown to impact psychomotor skills and performance of skilled activities such as cardiopulmonary resuscitation.”
In a related editorial, Julia H. Indik, MD, PhD, professor of medicine, Flinn Foundation and American Heart Association endowed chair in electrophysiology and director of the cardiovascular disease fellowship program at Sarver Heart Center at the University of Arizona College of Medicine in Tucson, wrote: “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 [in-hospital cardiac arrest] patient.” – by Darlene Dobkowski
Disclosures: Ofoma reports he received support from the Geisinger Health System Foundation. Indik reports no relevant financial disclosures. The other authors report no relevant financial disclosures.
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