Pre-arrest and intra-arrest prognostic factors associated with survival after in-hospital cardiac arrest: systematic review and meta-analysis

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Abstract

Objective

To determine associations between important pre-arrest and intra-arrest prognostic factors and survival after in-hospital cardiac arrest.

Design

Systematic review and meta-analysis.

Data sources

Medline, PubMed, Embase, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception to 4 February 2019. Primary, unpublished data from the United Kingdom National Cardiac Arrest Audit database.

Study selection criteria

English language studies that investigated pre-arrest and intra-arrest prognostic factors and survival after in-hospital cardiac arrest.

Data extraction

PROGRESS (prognosis research strategy group) recommendations and the CHARMS (critical appraisal and data extraction for systematic reviews of prediction modelling studies) checklist were followed. Risk of bias was assessed by using the QUIPS tool (quality in prognosis studies). The primary analysis pooled associations only if they were adjusted for relevant confounders. The GRADE approach (grading of recommendations assessment, development, and evaluation) was used to rate certainty in the evidence.

Results

The primary analysis included 23 cohort studies. Of the pre-arrest factors, male sex (odds ratio 0.84, 95% confidence interval 0.73 to 0.95, moderate certainty), age 60 or older (0.50, 0.40 to 0.62, low certainty), active malignancy (0.57, 0.45 to 0.71, high certainty), and history of chronic kidney disease (0.56, 0.40 to 0.78, high certainty) were associated with reduced odds of survival after in-hospital cardiac arrest. Of the intra-arrest factors, witnessed arrest (2.71, 2.17 to 3.38, high certainty), monitored arrest (2.23, 1.41 to 3.52, high certainty), arrest during daytime hours (1.41, 1.20 to 1.66, high certainty), and initial shockable rhythm (5.28, 3.78 to 7.39, high certainty) were associated with increased odds of survival. Intubation during arrest (0.54, 0.42 to 0.70, moderate certainty) and duration of resuscitation of at least 15 minutes (0.12, 0.07 to 0.19, high certainty) were associated with reduced odds of survival.

Conclusion

Moderate to high certainty evidence was found for associations of pre-arrest and intra-arrest prognostic factors with survival after in-hospital cardiac arrest.

Systematic review registration

PROSPERO CRD42018104795

Related collections

Most cited references 92

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In-Hospital Cardiac Arrest

Lars Andersen, Mathias J. Holmberg, Katherine Berg … (2019)

In-hospital cardiac arrest is common and associated with a high mortality rate. Despite this, in-hospital cardiac arrest has received little attention compared with other high-risk cardiovascular conditions, such as stroke, myocardial infarction, and out-of-hospital cardiac arrest.

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Nurse staffing and inpatient hospital mortality.

Jack Needleman, Peter Buerhaus, V Shane Pankratz … (2011)

Cross-sectional studies of hospital-level administrative data have shown an association between lower levels of staffing of registered nurses (RNs) and increased patient mortality. However, such studies have been criticized because they have not shown a direct link between the level of staffing and individual patient experiences and have not included sufficient statistical controls. We used data from a large tertiary academic medical center involving 197,961 admissions and 176,696 nursing shifts of 8 hours each in 43 hospital units to examine the association between mortality and patient exposure to nursing shifts during which staffing by RNs was 8 hours or more below the staffing target. We also examined the association between mortality and high patient turnover owing to admissions, transfers, and discharges. We used Cox proportional-hazards models in the analyses with adjustment for characteristics of patients and hospital units. Staffing by RNs was within 8 hours of the target level for 84% of shifts, and patient turnover was within 1 SD of the day-shift mean for 93% of shifts. Overall mortality was 61% of the expected rate for similar patients on the basis of modified diagnosis-related groups. There was a significant association between increased mortality and increased exposure to unit shifts during which staffing by RNs was 8 hours or more below the target level (hazard ratio per shift 8 hours or more below target, 1.02; 95% confidence interval [CI], 1.01 to 1.03; P<0.001). The association between increased mortality and high patient turnover was also significant (hazard ratio per high-turnover shift, 1.04; 95% CI, 1.02 to 1.06; P<0.001). In this retrospective observational study, staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients' needs for nursing care. (Funded by the Agency for Healthcare Research and Quality.).

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Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review.

Peter Pronovost, Derek C Angus, Todd Dorman … (2002)

Intensive care unit (ICU) physician staffing varies widely, and its association with patient outcomes remains unclear. To evaluate the association between ICU physician staffing and patient outcomes. We searched MEDLINE (January 1, 1965, through September 30, 2001) for the following medical subject heading (MeSH) terms: intensive care units, ICU, health resources/utilization, hospitalization, medical staff, hospital organization and administration, personnel staffing and scheduling, length of stay, and LOS. We also used the following text words: staffing, intensivist, critical, care, and specialist. To identify observational studies, we added the MeSH terms case-control study and retrospective study. Although we searched for non-English-language citations, we reviewed only English-language articles. We also searched EMBASE, HealthStar (Health Services, Technology, Administration, and Research), and HSRPROJ (Health Services Research Projects in Progress) via Internet Grateful Med and The Cochrane Library and hand searched abstract proceedings from intensive care national scientific meetings (January 1, 1994, through December 31, 2001). We selected randomized and observational controlled trials of critically ill adults or children. Studies examined ICU attending physician staffing strategies and the outcomes of hospital and ICU mortality and length of stay (LOS). Studies were selected and critiqued by 2 reviewers. We reviewed 2590 abstracts and identified 26 relevant observational studies (of which 1 included 2 comparisons), resulting in 27 comparisons of alternative staffing strategies. Twenty studies focused on a single ICU. We grouped ICU physician staffing into low-intensity (no intensivist or elective intensivist consultation) or high-intensity (mandatory intensivist consultation or closed ICU [all care directed by intensivist]) groups. High-intensity staffing was associated with lower hospital mortality in 16 of 17 studies (94%) and with a pooled estimate of the relative risk for hospital mortality of 0.71 (95% confidence interval [CI], 0.62-0.82). High-intensity staffing was associated with a lower ICU mortality in 14 of 15 studies (93%) and with a pooled estimate of the relative risk for ICU mortality of 0.61 (95% CI, 0.50-0.75). High-intensity staffing reduced hospital LOS in 10 of 13 studies and reduced ICU LOS in 14 of 18 studies without case-mix adjustment. High-intensity staffing was associated with reduced hospital LOS in 2 of 4 studies and ICU LOS in both studies that adjusted for case mix. No study found increased LOS with high-intensity staffing after case-mix adjustment. High-intensity vs low-intensity ICU physician staffing is associated with reduced hospital and ICU mortality and hospital and ICU LOS.

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Author and article information

Contributors

Shannon M Fernando:

ORCID: http://orcid.org/0000-0003-4549-4289

Role: resident physician

Alexandre Tran: Role: resident physician

Wei Cheng: Role: senior methodologist

Bram Rochwerg: Role: assistant professor

Monica Taljaard: Role: associate professor

Christian Vaillancourt: Role: professor

Kathryn M Rowan: Role: professor

David A Harrison: Role: head statistician

Jerry P Nolan: Role: professor

Kwadwo Kyeremanteng: Role: assistant professor

Daniel I McIsaac: Role: assistant professor

Gordon H Guyatt: Role: distinguished professor

Jeffrey J Perry: Role: professor

Journal

Journal ID (nlm-ta): BMJ

Journal ID (iso-abbrev): BMJ

Journal ID (publisher-id): BMJ-UK

Journal ID (hwp): bmj

Title: The BMJ

Publisher: BMJ Publishing Group Ltd.

ISSN (Print): 0959-8138

ISSN (Electronic): 1756-1833

Publication date Collection: 2019

Publication date (Electronic): 04 December 2019

Volume: 367

Electronic Location Identifier: l6373

Affiliations

[1 ]Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada

[2 ]Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada

[3 ]School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada

[4 ]Department of Surgery, University of Ottawa, Ottawa, ON, Canada

[5 ]Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada

[6 ]Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada

[7 ]Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada

[8 ]Intensive Care National Audit and Research Centre, London, UK

[9 ]Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK

[10 ]Warwick Clinical Trials Unit, University of Warwick, Coventry, UK

[11 ]Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada

[12 ]Department of Medicine, McMaster University, Hamilton, ON, Canada

Author notes

Correspondence to: S M Fernando, Department of Emergency Medicine and Department of Critical Care, The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON K1Y 4E9, Canada sfernando@ 123456qmed.ca (or @shanfernands on Twitter)

Author information

Shannon M Fernando http://orcid.org/0000-0003-4549-4289

Article

Publisher ID: fers051261

DOI: 10.1136/bmj.l6373

PMC ID: 6891802

PubMed ID: 31801749

SO-VID: a8a49b0b-1e7e-4423-ac13-f45e01330b21

License:

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Pre-arrest and intra-arrest prognostic factors associated with survival after in-hospital cardiac arrest: systematic review and meta-analysis

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Abstract

Objective

Design

Data sources

Study selection criteria

Data extraction

Results

Conclusion

Systematic review registration

Related collections

Network Medicine

Most cited references 92

In-Hospital Cardiac Arrest

Nurse staffing and inpatient hospital mortality.

Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review.

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Author notes

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