Elsevier

Resuscitation

Volume 56, Issue 3, March 2003, Pages 247-263
Resuscitation

In-hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway

https://doi.org/10.1016/S0300-9572(02)00409-4Get rights and content

Abstract

Introduction: While pre-hospital factors related to outcome after out-of-hospital cardiac arrest (OHCA) are well known, little is known about possible in-hospitals factors related to outcome. Hypothesis: Some in-hospital factors are associated with outcome in terms of survival. Material and methods: An historical cohort observational study of all patients admitted to hospital with a spontaneous circulation after OHCA due to a cardiac cause in four different regions in Norway 1995–1999: Oslo, Akershus, Østfold and Stavanger. Results: In Oslo, Akershus, Østfold and Stavanger 98, 84, 91 and 186 patients were included, respectively. Hospital mortality was higher in Oslo (66%) and Akershus (64%) than in Østfold (56%) and Stavanger (44%), P=0.002. By multivariate analysis the following pre-arrest and pre-hospital factors were associated with in-hospital survival: age ≤71 years, better pre-arrest overall performance, a call-receipt-start CPR interval ≤1 min, and no use of adrenaline (epinephrine). The in-hospital factors associated with survival were: no seizures, base excess >−3.5 mmol l−1, body temperature ≤37.8 °C, and serum glucose ≤10.6 mmol l−1 1–24 h after admittance with OR (95% CI) 2.72 (1.09–8.82, P=0.033), 1.12 (1.02–1.23, P=0.016), 2.67 (1.17–6.20, P=0.019) and 2.50 (1.11–5.65, P=0.028), respectively. Pre-arrest overall function, whether adrenaline was used, body temperature, the occurrence of hypotensive episodes, and the degree of metabolic acidosis differed between the four regions in parallel with the in-hospital survival rates. Conclusion: Both pre-arrest, pre- and in-hospital factors were associated with in-hospital survival after OCHA. It seems important also to report in-hospital factors in outcome studies of OCHA. The design of the study precludes a conclusion on causability.

Sumàrio

Introdução: Enquanto que os factores pré-hospitalares relacionados com o resultado final após paragem cardı́aca pré-hospitalar (PCPH) são bem conhecidos, pouco se sabe sobre possı́veis factores intra-hospitalares relacionados com o resultado final. Hipóteses: Alguns factores intra-hospitalares estão associados ao resultado final em termos de sobrevida. Material e Métodos: Um estudo de observação de coorte histórico de todos os doentes admitidos ao hospital em circulação espontânea após PCPH de causa cardı́aca em quatro regiões diferentes da Noruega de 1995 a 1999: Oslo, Akershus, Ostfold e Stavanger. Resultados: Em Oslo, Akershus, Ostfold e Stavanger foram incluı́dos 98, 84, 91 e 186 doentes, respectivamente. A mortalidade hospitalar foi superior em Oslo (66%) e Akershus (64%) quando comparada com Ostfold (56%) e Stavanger (44%), P=0.002. Por análise multivariada associaram-se os seguintes factores pré-paragem e pré-hospitalares à sobrevida intra-hospitalar: idade ≤71 anos, melhor performance global pré-paragem, um intervalo chamada recebida/inı́cio de RCP ≤ 1min e não utilização de adrenalina. Os factores intra-hospitalares relacionados com a sobrevida foram: ausência de convulsões, base-excess >−3.5 mmol/l, temperatura corporal ≥37.8 °C e glicose sérica ≤10.6 mmol/l 1–24 horas após a admissão com OR (95% CI) 2.72 (1.09–8.82, P=0.033), 1.12 (1.0–1.23, P=0.016), 2.67 (1.17–6.20, P=0.019) e 2.50 (1.11–5.65, P=0.028), respectivamente. A função global pré-paragem, a utilização de adrenalina, a temperatura corporal, a ocorrência de episódios de hipotensão e o grau de acidose metabólica diferiram entre as quatro regiões, em paralelo com as taxas de sobrevida intra-hospitalar. Conclusão: Factores pré-paragem, pré-hospitalares e intra-hospitalares foram associados à sobrevida intra-hospitalar após paragem cardı́aca pré-hospitalar. Parece ser importante relatar os factores intra-hospitalares em estudos de resultado final de paragem cardı́aca pré-hospitalar. O desenho do estudo impede uma conclusão sobre causalidade.

Resumen

Introducción: Mientras los factores prehospitalarios relacionados con el resultado después del paro cardı́aco extrahospitalario (OHCA) son bien conocidos, muy poco se sabe acerca de los posibles factores intrahospitalarios relacionados con el resultado. Hipótesis: algunos factores intrahospitalarios están asociados con el resultado en términos de sobrevida. Material y método: Un estudio observacional de cohorte histórico de todos los pacientes admitidos al hospital con retorno a circulación espontánea, después de un OHCA debido a causa cardı́aca, en 4 regiones de Noruega 1995–1999: Oslo, Akershus, Østfold y Stavanger.Resultados: Se incluyeron 98, 84, 91 y 186 pacientes en forma retrospectivamente en Oslo, Akershus, Østfold y Stavanger. La mortalidad hospitalaria fue mas alta en Oslo (66%) y Akershus (64%) que en Østfold (56%) y Stavanger (44%), (P=0.002). Los siguientes factores previos al evento y pre hospitalarios fueron asociados con sobrevida intrahospitalaria por análisis multivariable: edad ≤71 años, mejor desempeño previo al evento, un intervalo recepción de llamada-inicio RCP ≤1 min, y el no uso de adrenalina. Los factores intrahospitalarios asociados con sobrevida están: ausencia de convulsiones, exceso de base >−3.5 mmol−1, temperatura corporal ≤37.8 °C, y glucosa sérica ≤10.6 mmol−1 1–24 horas después de admisión con OR (95% CI) 2.72 (1.09–8.82, P=0.033), 1.12 (1.0–1.23, P=0.016), 2.67 (1.17–6.20, P=0.019) y 2.50 (1.11–5.65, P=0.028), respectivamente. La función total previa al evento, uso de adrenalina, temperatura corporal, ocurrencia de episodios hipotensivos, grado de acidosis metabólica diferı́an entre las cuatro regiones en paralelo con las tasas de sobrevida a la hospitalización. Conclusión: Tanto los factores previos al evento como los factores intrahospitalarios estaban asociados con sobrevida a la hospitalización después de paro cardı́aco extrahospitalario. Parece importante reportar también los factores intrahospitalarios en los estudios de resultado en OHCA. El diseño de el estudio preludia una conclusión en causabilidad.

Introduction

Focus on survival after out-of-hospital cardiac arrest has concentrated mainly on emergency medical service (EMS) system factors. Guidelines on cardio-pulmonary resuscitation (CPR) addressing the four links [1] in the pre-hospital chain-of-survival have existed for several years. No such procedure exists for the postresuscitation period other than general brain-orientated intensive care. The question is whether the chain-of-survival should be extended with a fifth link: the in-hospital phase [2].

In Norway we became aware of an apparent discrepancy in the ratio of discharged alive/admitted to hospital alive after out-of-hospital cardiac arrest in different regions. We speculated whether this was a significant difference and if so, what the reason could be. In particular, we wondered if some of the observed differences could be due to in-hospital factors in addition to the well-known out-of-hospital factors.

Studies addressing in-hospital factors after out-of-hospital cardiac arrest are scarce and to our knowledge only one has compared such differences between hospitals [2]. Engdahl et al. reported on 1038 patients admitted to one of two hospitals in Gothenburg after what they defined as successful resuscitation, although 13–18% of the patients were still receiving CPR on arrival. They found a significant difference in the percentage being discharged alive between the two hospitals, but no differences in the prehospital variables. Due to missing data in a large proportion of the patients, they did not do multivariate analysis or attempt to explain the differences they observed in outcome due to in-hospital factors. Physiological variables were reported on admission only; the in-hospital factors were limited to cardiac interventions, cardiac investigations and complications.

We wanted to investigate whether there were significant differences in in-hospital mortality after out-of-hospital cardiac arrest in four regions in Norway, and whether any in-hospital factors were associated with outcome in terms of survival to discharge. We also wanted to check survival, performance and quality of life 1 year after the arrest.

Section snippets

Materials and methods

With approval from the Norwegian Board of Health, Norwegian Social Science Data Service, the Regional Committee for Research Ethics and the Central office for National Registration, we conducted a historical cohort observational study of all patients admitted to the emergency departments (ED) after non-traumatic witnessed and unwitnessed out-of-hospital cardiac arrest of cardiac origin in four different regions in Norway during the period 1995–1999. The hospital regions and periods of enrolment

Results

The study was carried out between June 2001 and May 2002. A total of 2592 Utstein-records were assessed for eligibility revealing a total of 1867 out-of-hospital cardiac arrests with resuscitation attempts. 1408 patients did not meet the inclusion criteria due to arrests of non-cardiac aetiology, resuscitation efforts failing in the field or were terminated shortly after arrival in the ED. Thus, 459 patients with sustained ROSC in the ED were enrolled. Six hospital notes in Østfold were

Discussion

There were several striking discrepancies between the four cohorts and some in-hospital factors were associated with differences in outcome. First of all, more than half of those admitted to hospital were discharged alive in Stavanger versus one third in Oslo and Akershus, intermediate in Østfold, and the differences in mortality rates among the groups were retained 1 year after arrest. Both the overall and cerebral performance levels at discharge were also highest in Stavanger. More patients

Acknowledgements

This study was supported by grants from the Norwegian Air Ambulance Foundation. The authors would like to thank MD Hans Morten Lossius (Rogaland Central Hospital, Stavanger) and pilot Bo Conneryd (Norwegian Air Ambulance, Høvik) in particular for their invaluable help with design of the database. We are indebted to MSc Mitchell Loeb (SINTEF Unimed, Oslo) for his enthusiasm, always in attendance with the statistical work. We are also grateful to the many secretaries and archive personnel for

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