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