Elsevier

Resuscitation

Volume 137, April 2019, Pages 14-20
Resuscitation

Clinical paper
Differences in durations, adverse events, and outcomes of in-hospital cardiopulmonary resuscitation between day-time and night-time: An observational cohort study

https://doi.org/10.1016/j.resuscitation.2019.01.023Get rights and content

Abstract

Background

Although patients with out-of-hospital cardiac arrest (OHCA) have a lower survival rate during night-time than during day-time, the cause of this difference remains unclear. We aimed to assess CPR parameters according to time period based on in-hospital cardiopulmonary resuscitation (IHCPR) duration and the frequency of iatrogenic chest injuries among OHCA patients.

Methods

This two-centre observational cohort study evaluated non-traumatic OHCA patients who were transferred between 2013–2016. These patients were categorised according to whether they received day-time treatment (07:00–22:59) or night-time treatment (23:00–06:59). Differences in IHCPR duration, CPR-related chest injuries, return of spontaneous circulation, and survivals to emergency department and hospital discharge were compared using a generalised estimating equation model adjusted for pre-hospital confounders. Sensitivity analysis was also performed using a propensity score matching method.

Results

Among 1254 patients (day-time: 948, night-time: 306), the night-time patients had a significantly shorter IHCPR duration (27.8 min vs. 23.6 min, adjusted difference: −5.1 min, 95% confidence interval [CI]: −6.7, −3.4), a higher incidence of chest injuries (40.4% vs. 67.0%, adjusted odds ratio [AOR]: 1.27, 95% CI: 1.20, 1.35), and a lower rate of return of spontaneous circulation (38.4% vs. 26.5%, AOR: 0.93, 95% CI: 0.88, 0.98). No significant differences were observed in the rates of survival to emergency department and hospital discharge. The propensity score-matched analysis revealed similar results.

Conclusions

Patients who underwent night-time treatment for OHCA had an increased risk of CPR-related chest injuries despite their shorter resuscitation duration. Further studies are needed to clarify the underlying mechanism(s).

Introduction

The survival rate after out-of-hospital cardiac arrest (OHCA) has improved because of the spread of bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator use. However, OHCA remains a major public health issue throughout the world,1 and Japan has approximately 120,000 OHCA cases that are transported annually.2, 3 Patients who receive night-time treatment for OHCA have a lower survival rate than patients who are treated during day-time, with this difference being potentially attributed to the decreased frequencies of witnessed cardiac arrest and bystander CPR.4 Furthermore, reduced quality of treatment (e.g., because of fewer staff who are tired and less motivated) may explain the lower survival rate after night-time treatment.5 However, few reports have examined CPR quality according to treatment time period.6

Quantitative evaluation of CPR quality and healthcare providers’ fatigue is challenging, especially in the clinical setting. However, fatigued healthcare providers may provide CPR of shorter duration with lower quality, which may increase the incidence of iatrogenic chest injuries. Thus, the present study aimed to evaluate the quality of manual chest compressions based on CPR duration and the frequency of iatrogenic chest injuries, according to night-time or day-time treatment, among patients with OHCA.

Section snippets

Study design and setting

This observational cohort study evaluated patients with OHCA between April 2013 and March 2016 (three fiscal years). The patients were transferred to two Japanese tertiary critical care centres: the Tokyo Medical and Dental University Hospital of Medicine or the Matsudo City Hospital. Each hospital receives approximately 150 patients with OHCA each year. Both hospitals provided a similar staffing, relative to patient admissions, during daytime (>2 board-certified emergency physicians, 3 medical

Results

The patient selection process identified 1254 patients with non-traumatic OHCA, including 948 day-time cases (75.6%) and 306 night-time cases (24.4%) (Supplemental Fig. S1). The numbers of OHCA cases according to admission times are shown in Fig. 1. The baseline characteristics of the two groups are summarised in Table 1. The day-time OHCA cases involved older patients (mean age: 69.0 years, standard deviation: 16.6 years) than the night-time group. However, the night-time group had relatively

Discussion

This cohort study evaluated CPR parameters (IHCPR duration and CPR-related chest injuries) according to the time of treatment among 1,254 patients with OHCA. Several recent retrospective studies have also suggested that night-time treatment of OHCA is associated with poorer outcomes than day-time treatment,14, 15, 16, 17 although the underlying mechanism(s) remain unclear. Some reports have attributed this difference to fewer staff who were fatigued and not motivated during night-time shifts.4,

Conclusion

This two-centre observational cohort study revealed that OHCA patients who were treated at night-time had a significantly shorter duration of in-hospital resuscitation, a significantly higher incidence of CPR-related chest injuries, and a significantly lower rate of ROSC. Further studies are needed to clarify the underlying mechanism(s) for these findings.

Conflicts of interest

None.

Role of the funding source

None.

Acknowledgments

We thank all included patients and their families as well as the physicians, nurses, paramedics, and other staff for performing CPR and assistance with the data acquisition. In addition, we thank Dr. Ayako Yoshiyuki, Dr. Raira Nakamoto, Dr. Nao Urushibata, and Dr. Junichi Aiboshi for direct patient care and their review and feedback regarding our manuscript.

References (30)

Cited by (8)

  • Association between time of out-of-hospital cardiac arrest and survival: Examination of the all-Japan Utstein registry and comparison with the 2005 and 2010 international resuscitation guidelines

    2021, International Journal of Cardiology
    Citation Excerpt :

    On the other hand, possible reasons for lower-quality hospital-based care during the night include the likelihood that there are fewer staff at this time, and that these staff are fatigued and have low motivation [21,22]. Takeyama et al. reported that the duration of in-hospital CPR is short, and that there is a higher incidence of iatrogenic chest injuries among OHCA patients at nighttime [23]. The rate of one-month survival and a favorable neurological outcome was much lower on Sunday and holiday evenings when compared to the daytime.

  • Time of out-of-hospital cardiac arrest is not associated with outcome in a metropolitan area: A multicenter cohort study

    2019, Resuscitation
    Citation Excerpt :

    Moreover, we do not present data related to the quality of in-hospital post arrest care such as target temperature management, percutaneous coronary intervention or extra corporal life support (ECLS) that may affect 30-day survival and neurological outcome. However, we previously demonstrated no difference in the quality of in-hospital post-arrest care by time of day at Vienna General hospital, the largest post-cardiac arrest care center in Vienna.14 In the present analysis, we found no significant difference in the quality of advanced life support during OHCA irrespective of day and daytime, with subsequently constant high rates of bystander CPR administered by both police officers and laypersons before EMS arrival.

View all citing articles on Scopus
View full text