Cardiopulmonary Resuscitation on the Wards: Who Survives?

Abstract & Commentary

Synopsis: In this review of outcomes from cardiopulmonary resuscitation among non-ICU inpatients in 3 urban teaching hospitals, no patient who had an unwitnessed cardiac arrest survived to discharge. Forty-four percent of patients with witnessed respiratory arrest returned to their homes, as compared with 13% of patients with witnessed cardiac arrest (21% for pulseless ventricular tachycardia or fibrillation, and 7% for pulseless electrical activity or asystole).

Source: Brindley PG, et al. Predictors of survival following in-hospital adult cardiopulmonary resuscitation. CMAJ. 2002;167(4):343-348.

Brindley and associates reviewed all cases of attempted resuscitation from cardiac and/or respiratory arrest that occurred during a 2-year period among hospitalized adult patients in all 3 teaching hospitals of the University of Alberta who were not in an ICU, the emergency department, or the operating room. Brindley et al sought to determine current overall survival rates, since existing data were mainly gathered decades ago, and both the hospital inpatient population and available therapies have changed. They also wished to determine associations among patient characteristics, the circumstances of the arrest, and other factors and survival.

There were 247 arrests during the study period, 58% of which were witnessed and 42% unwitnessed. Among patients with witnessed arrests, 48% were initially successfully resuscitated, 22% survived to hospital discharge, and 19% were able to return home. In contrast, only 21% of patients whose arrest was unwitnessed could be resuscitated, and only 1 patient (1%) survived to discharge and was able to return home. This latter patient had an isolated respiratory arrest; no patient who had an unwitnessed cardiac arrest survived to hospital discharge. The type of arrest strongly influenced outcome: Among the 143 patients with witnessed arrests, 44% with respiratory arrest returned home, as compared with 21% of those with pulseless ventricular tachycardia or ventricular fibrillation, and 7% of those with pulseless electrical activity (PEA) or asystole. The risk of not returning home after cardiac arrest was greater for patients whose events occurred on the night shift (11 pm-7 am) as compared to the day shift (7 am-3 pm), but age and sex were unrelated to survival.

Comment by David J. Pierson, MD

This study updates survival statistics for in-hospital cardiopulmonary arrest in the context of present-day inpatient severity of illness assessment and resuscitation techniques. Despite these evolutionary factors in inpatient healthcare, outcomes do not appear to have changed much in the last 40 years. Patients who are found already in cardiac arrest do not survive, even if they are initially resuscitated. About 1 patient in 5 who experiences a witnessed cardiac arrest and whose initial rhythm is pulseless ventricular tachycardia or ventricular fibrillation has a good outcome (defined in this study as being able to return home). For patients found initially in PEA or asystole, the chance is much less—only about 7% in this series.

While outcomes from cardiac or respiratory arrest in the ICU were not examined in this study and would likely be different, the present findings underscore the fact that cardiopulmonary resuscitation in patients sick enough to be in the hospital has a generally poor overall result. This is often at variance with what patients and their families believe. Resuscitation works much more often in the movies and on television. A review of TV medical dramas published in 1996 found that the initial survival rate following cardiopulmonary resuscitation was 75%, with two-thirds of the patients who arrested in the hospital surviving to discharge.1 As discussed by Brindley et al, these outcomes are 2 to 6 times better than those in any reported study. The onus is thus on physicians and others in the health care system to discuss actual expected survival should cardiac arrest occur and to find out about the expectations of patients and families. 

Dr. Pierson is Professor of Medicine University of Michigan, Medical Director Respiratory Care Harborview Medical Center, Seattle.

Reference

1. Diem SJ, et al. Cardiopulmonary resuscitation on television. Miracles and misinformation. N Engl J Med. 1996;334:1578-1582.