Clinical paperCardiac arrest in the Emergency Department: A report from the National Registry of Cardiopulmonary Resuscitation☆
Introduction
Various hospital units exist to meet the clinical needs of different populations, including the risk of unexpected life threatening events such as sudden cardiac arrest (CA). Location of CA events has been studied in the out-of-hospital arena1, 2, 3 and comparisons have been made between in-hospital and out-of-hospital settings.4, 5 However, detailed analysis of the location of in-hospital events has so far been limited to single centers.6, 7 The primary purpose of this analysis was to determine the characteristics and outcomes of Emergency Department (ED) CA events, and to compare them to CA events occurring in other units (ICU, general floor and telemetry floor).
Additionally, little is known about the characteristics of patients who develop CA in the ED, as a “primary” event vs. “recurrent” event (after successful resuscitation from out-of-hospital CA) and about the characteristics of patients who develop CA after a major traumatic injury. Secondary analyses profiled the characteristics and outcomes of these two subsets of ED CA patients (primary vs. recurrent, and trauma vs. non-trauma).
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Data collection and integrity
The National Registry of Cardiopulmonary Resuscitation (NRCPR) is a prospective, observational, multi-center registry of in-hospital CA events. Hospitals join voluntarily and pay a fee for data support and report generation.
Hospital medical records on sequential CA events are abstracted into a computer by trained, NRCPR-certified research coordinators at each institution. Data elements have standardized definitions allowing analysis from multiple sites. Data abstractors are required to
Patient characteristics
A total of 60,852 first pulseless CA events were included in the analysis (7435 in the ED, 9806 on the non-telemetry floor, 13,135 on the telemetry floor and 30,472 in the ICU). Table 1 summarizes patient demographic characteristics by event location. Compared to hospital in-patient floor and ICU patients, the ED had the largest percentage of patients with no known pre-existing conditions and the largest percentage of patients with pre-existing major trauma and acute non-stroke CNS events. The
Discussion
It is difficult to compare our findings with those of other investigators since we could only find small case series from individual institutions reporting the outcomes of blunt or penetrating traumatic CA.10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 ED CAs are unique in many ways. Patients suffering a CA in the ED show a mixture of characteristics from the out of hospital and in-hospital arrest populations. Because patients are admitted to the ED with an acute problem, one might assume they
Limitations
Limitations of NRCPR include: (1) registry hospitals may not be representative of all hospitals; (2) no on-site validation of data collection; (3) no follow-up after hospital discharge and (4) the only assessment of neurologic outcomes are the OPC and CPC scores. In addition, although medication use is tracked, NRCPR does not attempt to assess clinical eligibility for each medication. These limitations are similar to those of other contemporary in-hospital registries.
Conclusions
This is the largest analysis to date of in-hospital CA events that looks at the unique features and outcomes of events occurring in the ED compared to other hospital locations. Our results suggest that ED CA patients are a unique population and have better survival and neurological outcomes compared to patients arresting in other locations. Primary ED CA patients have a better chance of survival to discharge than those who re-arrest following a successful pre-hospital resuscitation. Traumatic
Conflict of interest
None.
Acknowledgements
We acknowledge the AHA; Digital Innovation, Inc., especially Mr. Scott M. Carey for providing technical and database support; and all participating hospitals for providing the data in this analysis.
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2008.03.007.