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