|Year : 2014 | Volume
| Issue : 4 | Page : 479-481
Outcome of in-hospital, out of intensive care and operation room cardiac arrests in a tertiary referral hospital in India: Comparison of outcomes of two audits
Murali Chakravarthy1, Sona Mitra1, Latha Nonis2, Naveen Yellappa1
1 Department of Anesthesia, Critical Care and Pain Relief, Nursing, Fortis Hospitals, Bengaluru, Karnataka, India
2 Nursing, Fortis Hospitals, Bengaluru, Karnataka, India
|Date of Web Publication||17-Aug-2014|
Dr. Murali Chakravarthy
Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru - 560 076, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chakravarthy M, Mitra S, Nonis L, Yellappa N. Outcome of in-hospital, out of intensive care and operation room cardiac arrests in a tertiary referral hospital in India: Comparison of outcomes of two audits. Indian J Anaesth 2014;58:479-81
|How to cite this URL:|
Chakravarthy M, Mitra S, Nonis L, Yellappa N. Outcome of in-hospital, out of intensive care and operation room cardiac arrests in a tertiary referral hospital in India: Comparison of outcomes of two audits. Indian J Anaesth [serial online] 2014 [cited 2019 Oct 19];58:479-81. Available from: http://www.ijaweb.org/text.asp?2014/58/4/479/139019
| Introduction|| |
Varied rates of survival to discharge after cardiac arrest are cited in the literature. ,,, Factors such as appropriate training for the medical and the paramedical staff, speed of response, early defibrillation, type of the ward, part of the shift and weekends have been implicated in varying outcomes. ,,,, Code blue is the term used for the process of calling for assistance via phone. We published our data for the period of the years 2007-2009 and noted the survival to discharge rate of 30%.  However, the current audit spanned 5 years from January 2007 to December 2011. Data from two periods of time were compared. Despite on-going training, several quality measures, the outcome of the recent batch of cardiac arrest victims was not encouraging. Survival to discharge decreased from 30% to 16%. This may be attributable to increasing incidence of comorbidities in the recent times.
| Methods|| |
The first set of data-data A from 2007 to 2009 was compared with data B of 2009-2011. The procedure for initiating 'code blue' ('code 555') is in place at the hospital for treating individuals with cardio-respiratory collapse. A phone call to 555 from any of the house phones by any of the staff (nurses, doctors or technicians) would automatically dial the emergency room staff, who by pressing buttons 1-4 would dial automatically dial the 'code phone' manned by a registrar from medical intensive care unit, coronary care unit, anaesthesiology and nursing supervisor who are all located within the hospital. This phone call also informs the phone holder from where the code has been raised. The receiver will immediately rush to the location from where the code has been raised and attend to the victim of cardio-respiratory arrest. The co morbidities, the gender distribution, time to arrive at the scene, locations of the arrests, types of electrical arrest patterns on ECG, outcomes in terms of mortality, return of spontaneous circulation (ROSC) and survival rates were assessed.
| Results|| |
There were 201 code blue calls in the present audit and 45 of those were false calls. The comorbidities among the patient in this audit are shown in [Table 1]. Among the patients who received cardiopulmonary resuscitation (CPR) (n = 156), there were 103 (66%) males and the rest females. During the period 2009-11, significant improvement in the time to commencement of resuscitation was observed [Figure 1]. The number of code blue calls in various locations and the mortality did not vary significantly during the two periods [Table 2]. The rhythm of initial presentation is shown in [Table 3] (pulseless electrical activity in 59, ventricular fibrillation in 34, asystole in 63 patients). Among the 156 cases that required resuscitation via the activation of code blue, 101 had a return of spontaneous circulation (ROSC); the rest (55) could not be resuscitated. The overall survival between the periods A and B was 30.8 and 16.6% respectively [Table 3]. Fifty patients from data A and only 24 (48%) survived to discharge even after ROSC, and 51 in data B had ROSC and only 13 (25%) survived to discharge. None of the patients who sustained cardiac arrest in either the emergency room or dialysis room survived. 25% of patients in the ward and 20% in the cardiac catheterization laboratory survived to discharge. More patients who suffered cardiac arrest during the day shift survived (48%) than night (20%).
|Figure 1: Comparison in the time to start resuscitation. X axis: Time in minutes, Y axis: Number of patients|
Click here to view
| Discussion|| |
False calls are always better than not being sounded at all; 45 of the calls of the total 201 code blue calls in the present study were false calls. In their study, Hein and coworkers showed the incidence of false cardiac arrest at 21%.  In yet another study, Kenward et al. found 150 incidents of false cardiac arrests among 512 calls (29%). There were no patients with single comorbidities in the data for 2009-11 in contrast to the earlier one (2007-09) and this could be taken as a major contributor for a fall in survival to discharge rate from 30% to 16%. About 73.6% of patients had two or more comorbidities in recent period, whereas in the earlier data only about 50% had >1 comorbidity. Decreased time to commencement of resuscitation in 2009-11 period can be ascribed to improved communications and manpower management and a lesson learnt based on the first audit. The rhythm of initial presentation between two periods were almost identical. The observation of better outcomes during resuscitation during day time than night times was as observed previously and points to the area for improvement.
This audit had a few weaknesses; the first one is that the data collection was retrospective. Second, most of the patients admitted to our facility were elective adults; therefore, true picture about outcomes after cardiac arrest in children, due to trauma, sepsis and multiorgan failure may not have been captured in our audit. Therapeutic hypothermia was used in 16 of our patients, their outcome and complications have not been included in this audit.
| Conclusion|| |
Despite continued quality initiative such as basic life support training, feedback about basic life support training, more patients being resuscitated earlier and pre and post BLS knowledge assessment to improve the quality of CPR, the outcome of resuscitation after cardiac arrest did not improve in our facility. This possibly is due to increasing morbidity trend in our patient population.
| References|| |
|1.||Hershey CO, Fisher L. Why outcome of cardiopulmonary resuscitation in general wards is poor. Lancet 1982;1:31-4. |
|2.||Peatfield RC, Sillett RW, Taylor D, McNicol MW. Survival after cardiac arrest in hospital. Lancet 1977;1:1223-5. |
|3.||Bedell SE, Delbanco TL, Cook EF, Epstein FH. Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med 1983;309:569-76. |
|4.||Khan NU, Razzak JA, Ahmed H, Furqan M, Saleem AF, Alam H, et al. Cardiopulmonary resuscitation: Outcome and its predictors among hospitalized adult patients in Pakistan. Int J Emerg Med 2008;1:27-34. |
|5.||Chakravarthy M, Mitra S, Nonis L. Outcomes of in-hospital, out of intensive care and operation theatre cardiac arrests in a tertiary referral hospital. Indian Heart J 2012;64:7-11 |
|6.||Hein A, Thorén AB, Herlitz J. Characteristics and outcome of false cardiac arrests in hospital. Resuscitation 2006;69:191-7 |
|7.||Kenward G, Robinson A, Bradburn S, Steeds R. False cardiac arrests: The right time to turn away? Postgrad Med J 2007;83:344-7 |
[Table 1], [Table 2], [Table 3]