Elsevier

Resuscitation

Volume 54, Issue 2, 1 August 2002, Pages 115-123
Resuscitation

Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital

https://doi.org/10.1016/S0300-9572(02)00098-9Get rights and content

Abstract

Aims: To determine the incidence of avoidable cardiac arrest among patients who had received resuscitation in a district general hospital. To establish how location and individual or system factors influence avoidable cardiac arrest in order to develop an evidence-based preventive strategy. Methods: Expert panel review of case-notes from 139 consecutive adult in-hospital cardiac arrests over 1 year. Results: There were 32 348 adult admissions in 1999 with 1023 deaths. The cardiac arrest team was activated 139 times: 118 were for primary in-hospital cardiac arrest. The cardiac arrest rate excluding ‘do not attempt resuscitation’ (DNAR) cases was 3.8/1000 admissions. In 88.5% of deaths there was a DNAR policy. Survival to hospital discharge following resuscitation was 14%. Among the 118 cases, the panel unanimously agreed that 61.9% of arrests were potentially avoidable, rising to 68% when emergency department arrests were excluded (66 and 73% for majority opinion). Cardiac arrests were more likely at the weekend than during the week (P=0.02). The odds of potentially avoidable cardiac arrest was 5.1 times greater for patients in general wards than critical care areas (P<0.001); patients in critical care areas were more likely to survive (P<0.001). The odds of potentially avoidable cardiac arrest was 12.6 times greater for patients nursed in a clinical area judged ‘inappropriate’ for their main complaint (P<0.002, Fisher's exact test) compared to those nursed in ‘appropriate’ areas. The panel agreed that 100% of potentially avoidable arrests were judged to have received inadequate prior treatment. Clinical signs of deterioration in the preceding 24 h were not acted upon in 48%, and review was confined to a house officer in 45%. Conclusion: The majority of treated in-hospital cardiac arrests are potentially avoidable. Multiple system failures include delays and errors in diagnosis, inadequate interpretation of investigations, incomplete treatment, inexperienced doctors and management in inappropriate clinical areas.

Sumàrio

Objectivo: Determinar a incidência de paragens cardı́acas evitáveis entre as vı́timas de PCR que foram alvo de manobras de reanimação cardio-respiratória (RCR) num hospital distrital. Estabelecer a eventual relação entre o local da PCR e factores individuais e do sistema que possam relacionar-se com as PCR evitáveis, desenvolvendo desta forma uma estratégia preventiva com base na evidência. Métodos: Um painel de peritos reviu as notas de 139 PCR intra-hospitalares consecutivas em adultos durante um ano. Resultados: Houve 32348 admissões de adultos em 1999 com 1023 mortes. A equipa de paragem cardı́aca foi activada 139 vezes: 118 por PCR intra-hospitalar primária. A taxa de paragem cardı́aca excluindo os casos ‘do not attempt resuscitation’ (DNAR) foi de 3.8/1000 admissões. Em 88.5% das mortes existia uma polı́tica de DNAR. A sobrevivência à alta hospitalar após reanimação foi de 14%. Entre os 118 casos, os peritos do painel concordaram unanimemente que 61.9% das paragens eram potencialmente evitáveis, aumentando para 68% quando foram excluı́das as paragens cardı́acas no departamento de Emergência (66 e 73% por opinião da maioria). As paragens cardı́acas eram mais prováveis ao fim de semana do que durante a semana (P=0.02). A taxa de paragem cardı́aca potencialmente evitável foi 5.1 vezes superior para os pacientes em enfermarias gerais do que para os pacientes em áreas de cuidados crı́ticos (P<0.001); os pacientes em áreas de cuidados crı́ticos tinham maior probabilidade de sobreviver (P<0.001). A taxa de paragens cardı́acas potencialmente evitáveis foi 12.6 vezes superior para vı́timas a quem eram prestados cuidados em áreas clı́nicas julgadas como ‘inapropriadas’ para a sua queixa principal (P<0.002, teste exacto de Fisher) comparativamente com aqueles a quem foram prestados cuidados em áreas consideradas ‘apropriadas’. O painel de peritos concordou que em 100% das paragens potencialmente evitáveis o tratamento prévio foi inadequado. Sinais clı́nicos de deterioração nas 24 horas precedentes não foram detectados em 48% dos casos, e a revisão esteve confinada a um interno geral em 45%. Conclusão: A maioria das paragens cardı́acas intra-hospitalares tratadas eram potencialmente evitáveis. Falências de multiplos sistemas incluiam atrasos e erros no diagnóstico, interpretação inadequada das investigações realizadas, tratamento incompleto, médicos inexperientes e abordagem em áreas clı́nicas inapropriadas.

Resumen

Objetivos: Determinar la incidencia de paro cardı́aco prevenible entre los pacientes que han recibido reanimación cardiopulmonar en un hospital general distrital. Establecer de que manera influyen en el paro cardı́aco evitable, la localización y factores individuales o del sistema, para desarrollar una estrategia de prevención basada en evidencia. Métodos: Revisión, por un panel de expertos, de las notas de 139 paros cardı́acos de adultos intrahospitalarios consecutivos ocurridos en un año. Resultados: hubo 32348 admisiones de adultos en 1999 con 1023 muertes. El equipo de paro cardı́aco fue activado 139 veces: 118 de ellas por paro cardı́aco primario intrahospitalario. La tasa de paro cardı́aco, excluyendo los casos con ‘orden de no intentar reanimación’(DNAR) fue 3.8/1000 admisiones. En el 88.5% de las muertes habı́a polı́tica de DNAR. La sobrevida al alta hospitalaria después de reanimación fue 14%. Entre los 118 casos, el panel acordó unánimemente que 61,9% de los paros eran potencialmente prevenibles, elevándose a 68% cuando se excluyen los paros de la unidad de emergencia (66 y 73% por opinión mayoritaria). Los paros eran mas probables durante los fines de semana que durante la semana (P=0.02). La probabilidad de paro cardı́aco potencialmente evitable fue 5.1 veces mayor para pacientes en salas comunes que en áreas de cuidados crı́ticos (P<0.001); los pacientes en áreas de cuidados crı́ticos tenı́an mas probabilidades de sobrevivir (P<0.001).La probabilidad de paro cardı́aco potencialmente evitable fue 12.6 veces mayor para pacientes cuidados en áreas clı́nicas juzgadas ‘inapropiadas’ para su problema principal (P<0.002, test exacto de Fisher) comparando aquellos cuidados en áreas juzgadas como ‘apropiadas’. El panel acordó que en el 100% de los paros cardı́acos potencialmente evitables fueron juzgados como habiendo recibido tratamiento previo inadecuado. Los signos clı́nicos de deterioro en la 24 horas previas no recibieron acciones consecuentes en 48%, y la revisión fue confinada a un auxiliar en 45%. Conclusiones: La mayorı́a de los paros cardı́acos intrahospitalarios tratados son potencialmente evitables. Las fallas en múltiples sistemas incluyen demora y errores en el diagnóstico, interpretación inadecuada de investigaciones, tratamiento incompleto, doctores inexpertos y manejo en áreas clı́nicas inadecuadas.

Introduction

There are an estimated 850 000 adverse events per year in NHS hospitals resulting in harm to patients [1]. Risk factors for in-hospital cardiac arrest [2], [3], [4], [5] and for unplanned intensive care unit admission from a general ward [6], [7], [8], [9] have been widely described. Observable evidence of deterioration in up to 84% of cases in the 8 h prior to arrest has led authors to conclude that cardiac arrest may often be avoidable [2], [3], [4]. No study to date has addressed the overall incidence of avoidable in-hospital cardiac arrest and resultant avoidable death.

A small study of hospital deaths following emergency admissions resulting in medico-legal claims showed 69% (20/29) were potentially avoidable [10], but the population was highly selected. Effective risk management necessitates that avoidable in-hospital cardiac arrest is minimised. A reduction in avoidable cardiac arrest requires trends in failure of individual doctors and nurses to be identified [3], [11], together with the organisational factors that provide the conditions in which errors occur [12].

As a preventive strategy, hospitals in Australia and the United Kingdom have used clinical teams with empirical-based activation criteria [1], [13], [14], [15], [16]. Our study aimed to determine the incidence of avoidable cardiac arrest among patients who had received resuscitation, and to establish how the location and individual or system factors influenced avoidability in order to develop an evidence-based preventive strategy.

Section snippets

Setting

An acute district general hospital in south-east England with 700 beds (6 intensive care, 5 high dependency, 4 coronary care) and a catchment population of around 365 000. The cardiac arrest team (CAT) is led by a medical registrar or senior house officer and includes an anaesthetist, resuscitation officer, house officer/s and ward-based nursing staff. The CAT is alerted to an arrest and its location via a pager, triggered by a central switchboard immediately following notification of cardiac

Incidence

There were 32 348 adult hospital admissions for 1999. The total number of adult deaths was 1023 (1014 patients died on a ward, and 9 further patients died in the ED). In 905 cases no resuscitation attempt was made (takes account of the one patient with a cardiac arrest secondary to a respiratory arrest, where resuscitation was attempted, and who died), revealing a DNAR rate of 88.5% within the population who died. Specifically, the CAT is mobilised for all patients in this hospital who are

Discussion

The likelihood of potentially avoidable cardiac arrest is greater on a general ward than a critical care area, and is also greater if the patient is nursed in an ‘inappropriate’ clinical area that does not reflect the needs of the primary condition. Medical patients on surgical wards or patients on general wards rather than critical care areas in part reflects a failure to appreciate the severity of the condition, and in part reflects a high bed occupancy. When the hotel is almost full, the

Conclusion

A systematic approach to the prevention of in-hospital cardiac arrest is needed. Steps are required to reduce diagnostic error, improve early detection of deterioration, improve activation of appropriate medical resources, and to ensure that clinicians follow established guidelines when they respond. While this provides a safety net, it may not cancel the risk of being unable to place patients in appropriate clinical areas that arises through high bed occupancy.

This study was the first step in

Acknowledgements

Dr P. Andrews and H. Gage are thanked for their independent critical appraisal. Funding: This research project is funded for 2 years from November 1999 by the Defence Secondary Care Agency's Clinical Effectiveness budget.

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