| Summary: | 碩士 === 高雄醫學大學 === 公共衛生學研究所 === 99 === Background:
The outcome after in-hospital cardiac arrest (IHCA) on general wards continues to be poor with a sustained return of spontaneous circulation (ROSC) of only about 40% to 60%. Only between 3% and 30% of patients who receive cardiopulmonary resuscitation (CPR) following a cardiopulmonary arrest (CPA) in a hospital environment will survive to be discharged.
In-hospital CPR will consume substantial healthcare resources, CPR should be applied only if it is considered to be effective and useful as well as not harmful. Accurate identification of poor prognostic factors on admission or before resuscitation could potentially prevent ineffective and useless CPR. This may also assist physicians to formulate a do-not-resuscitate order, which could reduce patient suffering, minimize family trauma and limit health care costs. However, prior studies have been undertaken to accurate estimate of IHCA prognoses were difficult and compounded by area and patient heterogeneity, such as the incidence of coronary artery disease and ventricular dysrhythmias as the initial rhythm in IHCA patients was low in oriental countries. The influence of different disease patterns in different areas on the results of IHCA has not been studied.
Most prior efforts to model CPA survival focused on intra-arrest rather than pre-arrest factors. However , intra-arrest interventions (characterizations of care such as warning system of arrest call, response time, medical emergency team activation and on site resuscitation efforts), as they could not be applied prospectively for advance care planning and because they have limitations (e.g. unknown CPR quality and poor record quality). The survival probability after IHCA may be more accurately estimated by the occurrence in time of the pre-arrest morbidity of patients. Therefore, improved understanding of pre-arrest factors associated with mortality could help advance care planning. In addition, most studies enrolled different areas or different facilities (like monitored and non-monitored setting , intensive care units ,general wards and emergency department) of IHCA patients simultaneously, that is, coupled with patient heterogeneity, makes it hard for one model to perform well on all cardiac arrest patients, especially to generate a rapid and standardized risk stratification protocol.
Objective: The aim of this study was to investigate the key pre-arrest factors to predict post-cardiopulmonary arrest outcome in adult patients with in-hospital cardiopulmonary resuscitation on the general wards.
Material and methods: We conducted a retrospective chart review by examining medical records of all adult patients who underwent in-hospital cardiopulmonary resuscitation from January 2007 to December 2010 at the Kaohsiung Chang Gung Memorial Hospital.
Results: A total of 544 patients on the general wards were analyzed for the event variables and resuscitation results. The rate of establishing a ROSC was 40.1%, the rate of survival to discharge was 5.1% and only 0.4% of the studied populations were discharged with good neurologic function. 14.8% of the patients resuscitated had coronary artery disease. ventricular tachycardia or ventricular fibrillation(VT/VF) was the initial rhythm in only 3.9% patients. Most of the patients (90.6%) came from emergency department. Pre-arrest factors including high Charlson Comorbidity Index(≧9) (OR 0.251, 95% CI 0.098-0.646), cardiac comorbidity before admission(OR 0.612, 95% CI 0.401-0.933), Metastatic malignancy(OR 0.485, 95% CI 0.282-0.835) , arrest time on midnight shift(OR 0.403, 95% CI 0.252-0.642), activation of medical emergency teams on resuscitation event(OR 0.278, 95% CI 0.119-0.648) were independently associated with low possibility of sustained ROSC. Diabetes as comorbidity before admission (OR 0.409, 95% CI 0.175-0.959) and VT/VF as initial presenting pulseless rhythm(OR 0.143, 95% CI 0.032-0.647) were independently associated with high survival, whereas deteriorated disease course was independently associated with low survival(OR 3.922, 95% CI 1.601-9.611).
Conclusions: The results of our study demonstrated a low survival rate of cardiopulmonary resuscitation on general wards in a medical center. Charlson Comorbidity Index was a more reliable pre-arrest indicator for outcome prediction after IHCA on the general wards. Cardiac comorbidity before admission was not a positive predictor for ROSC or survival to hospital discharge on the general wards. Delayed activating of medical emergency teams was related to poor outcome of ROSC in this study. Deficiency of intensive care unit beds and inadequate cardiac monitoring contribute to the lower survival rate on general wards. The mechanism for the poor survival in CPA events of general wards is likely multifactorial, potentially including biological differences in patients as well as health care staff and hospital staffing and operational factors. These data suggests the need to focus on hospital-wide resuscitation system processes of care that can potentially improve patient safety and survival following cardiac arrest on the general wards.
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