Is hospital care of major importance for outcome after out-of-hospital cardiac arrest?: Experience acquired from patients with out-of-hospital cardiac arrest resuscitated by the same Emergency Medical Service and admitted to one of two hospitals over a 16-year period in the municipality of Göteborg
Introduction
In the past 2 or 3 decades, considerable efforts have been made to describe factors associated with out-of-hospital cardiac arrest [1], [2], [3], [4]. Since the introduction of the Utstein reporting style [3], detailed intersystem comparison is at last possible. The ‘chain of survival’ concept [4], is now a widely established description of prehospital measures, each with an effect on survival. An increasing percentage of these patients are now being hospitalised and discharged alive. This is confirmed by two recently published European reports [5], [6], in which the survival-to-discharge rates for witnessed out-of-hospital ventricular fibrillation have risen to the region of 35%. Most of the studies of out-of-hospital cardiac arrest published so far have focused on factors related to the Emergency Medical Services (EMS), including time intervals during EMS activation and resuscitation, the presence of a bystander performing cardiopulmonary resuscitation (CPR), the training level of EMS crews and the number of tiers. Since prehospital factors have proven themselves in several studies to have a major effect on the patients outcome [5], [7], [8], [9], this focus is easily understood. However, with a growing percentage of patients admitted to emergency departments (ED), intensive care and modern cardiological investigations and interventions, we believe that the importance of the hospital phase of management of out-of-hospital cardiac arrest may increase.
The aim of this study was to describe patient characteristics, in-hospital investigations and interventions and early mortality among patients resuscitated after out-of-hospital cardiac arrest. To achieve this, we examined the medical history, and prehospital and hospital course of two cohorts of patients suffering an out-of-hospital cardiac arrest and recruited from the same municipality and resuscitated by the same EMS but admitted to one of the two city hospitals.
Section snippets
Target population
Since 1974, the municipality of Göteborg has had an area of 455 km2, excluding areas of water. The population increased from 427 644 to 457 400 between 1980 and 1996. During the time of the survey there was an increase of 21 846 inhabitants in the catchment area of Sahlgrenska Hospital and an increase of 7932 inhabitants in Östra Hospital. Of the total population, 49% are men. The age distribution of the population are as follows: 0–4 years, 6.1%; 5–14 years, 10.6%; 15–24 years, 12.9%; 25–34
Statistics
Pitman’s non-parametric test was used to test for difference between the two hospitals. This test includes Fisher’s exact test for dichotomous variables. Logistic regression was used to calculate adjusted P-values for difference in hospital mortality. Since information upon several of the baseline characteristic and resuscitation related factors were missing in a large proportion of the patients, we analysed the influence of one factor at a time by comparing the difference between hospitals in
Results
During the study period, there were 4453 out-of-hospital cardiac arrests with resuscitation attempts in the municipality. A total number of 1038 cases (23%) were successfully resuscitated and admitted to the two hospitals; 579 were admitted to Sahlgrenska Hospital and 459 to Östra Hospital. These 1038 cases involved a total of 1021 patients, i.e. some patients were admitted alive after out-of-hospital cardiac arrest more than once. In the mortality results, only the first episode is taken into
Discussion
The main advantage of this study is that it represents all the patients in one municipality who where hospitalised in the two city hospitals after being resuscitated by the same ambulance organisation. The aim of this study was to evaluate hospital logistics, in-hospital investigations and interventions and hospital mortality among patients resuscitated after out-of-hospital cardiac arrest. Despite the large number of studies of out-of-hospital cardiac arrest, only very few have so far focused
Conclusions
Of 1038 patients successfully resuscitated after out-of-hospital cardiac arrest and admitted to one of the two city hospitals in Göteborg, 253 (43.7%) survived to discharge from Sahlgrenska Hospital and 152 (33.1%) were discharged from Östra Hospital. Perhaps more importantly 50 and 41% were discharged alive when considering only victims of witnessed arrest of a cardiac etiology, a better comparator than cardiac arrest overall. There are three major hypothesis, which might explain this
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