Background Hospitals often employ Medical Emergency Teams (MET) to respond to patients with acute physiological decline so as to prevent deaths from in-hospital cardiac arrest (IHCA). We determined the frequency of missed opportunities for MET evaluation, defined as no MET evaluation prior to IHCA despite evidence of severe vital sign abnormalities ≥ 1 hour preceding cardiac arrest. Methods Within Get With The Guidelines-Resuscitation, we identified 21,913 patients from 274 hospitals with IHCA on general inpatient or telemetry floors who would be eligible for a MET evaluation prior to IHCA. We determined the proportion of patients with missed opportunities for MET evaluation, defined as no MET evaluation before IHCA despite at least one severe vital sign abnormality (pulse >150 or <30, respiratory rate >35 or <8, systolic blood pressure <80, and oxygen saturation <80%) 1, 2, and 4 hours before IHCA. The relationship between a hospital's proportion of missed opportunities for MET evaluation and its risk-standardized rate of survival to discharge for IHCA (derived using hierarchical linear regression models) was then evaluated. Results Overall, few (3814 [17.4%]) patients with IHCA had a preceding MET evaluation, and the odds of a MET evaluation varied by >80% across hospitals (median: 14.6% [IQR: 9.1% to 22.2%]; median odds ratio, 1.82). Vital sign data were available for 13,115 (72.5%) of the 18,099 patients without MET evaluation. Of these patients, 5243 (40.0%), 4078 (31.1%), and 1767 (13.4%) had at least one severe vital sign abnormality ≥ 1, 2, and 4 hours before IHCA, respectively. Hospitals with the highest proportion of unevaluated patients despite severe vital sign abnormalities 2 and 4 hours preceding cardiac arrest had the lowest IHCA survival rate (correlation of -0.14 [P=0.04] and -0.16 [P=0.01], respectively). Conclusions Although MET teams are designed to prevent IHCA, many patients with severe vital sign abnormalities prior to IHCA did not have a MET evaluation, and hospitals with higher rates of unevaluated patients had lower IHCA survival. These findings suggest missed opportunities to efficiently use MET teams in current practice.
Background Medical Emergency Teams (METs) are designed to respond to signs of clinical decline in order to prevent cardiopulmonary arrest and reduce mortality. The frequency of MET activation prior to pediatric cardiopulmonary resuscitation (CPR) is unknown. Methods Within the Get With The Guidelines-Resuscitation Registry (GWTG-R), we identified children with bradycardia or cardiac arrest requiring CPR on the general inpatient or telemetry floors from 2007–2013. We examined the frequency with which CPR outside the ICU was preceded by a MET evaluation. In cases where MET evaluation did not occur, we examined the frequency of severely abnormal vital signs at least 1 hour prior to CPR that could have prompted a MET evaluation but did not. Results Of 215 children from 23 hospitals requiring CPR, 48 (22.3%) had a preceding MET evaluation. Children with MET evaluation prior to CPR were older (6.8 ± 6.5 vs. 3.1 ± 4.7 years of age, p < 0.001) and were more likely to have metabolic/electrolyte abnormalities (18.8% vs. 5.4%, p=0.006), sepsis (16.7% vs. 4.8%, p=0.01), or malignancy (22.9% vs. 5.4%, p<0.001). Among patients who did not have a MET called and with information on vital signs, 55/141 (39.0%) had at least one abnormal vital sign that could have triggered a MET. Conclusion The majority of pediatric patients requiring CPR for bradycardia or cardiac arrest do not have a preceding MET evaluation despite a significant number meeting criteria that could have triggered the MET. This suggests opportunities to more efficiently use MET teams in routine care.
IntroductionEarly on in the COVID-19 pandemic, investigators reported poor survival rates (<3%) after in-hospital cardiac arrest (IHCA) among patients with COVID-19 infection in the US and China. [1][2][3] These findings have prompted discussions regarding universal do-not-resuscitate orders for patients with COVID-19. 4 However, these results were from single-center studies that comprised only 295 patients with COVID-19 in hospitals that were overwhelmed early during the pandemic. Whether the poor IHCA survival rate reported in earlier studies is broadly representative of patients with COVID-19 in US hospitals remains unknown. This study examined the association of COVID-19 infection with survival outcomes of US adults after IHCA. MethodsThis cohort study was approved by the Saint Luke's Hospital Institutional Review Board. The board waived the requirement for informed consent because only deidentified data were used. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.The study used data from the American Heart Association Get With the Guidelines-Resuscitation (GWTG-R) registry, which contains detailed information on patients who experience cardiac arrest at participating hospitals in the United States. Within the GWTG-R registry, we identified all adults (aged Ն18 years) who developed IHCA during March to December 2020. Race and ethnicity were self-reported by the study patients, and these data were collected in the GWTG-R registry to examine disparities in care and outcomes of IHCA patients. We constructed multivariable hierarchical regression models to compare survival to discharge and return of spontaneous circulation (ROSC) for 20 minutes or more among patients with and without a suspected or confirmed COVID-19 infection. These models included hospital site as a random intercept and patient variables and calendar month as fixed effects. We used a Poisson link to directly estimate rate ratios.Data are presented as relative risks (RRs) with 95% CIs. Details on the GWTG-R registry, study cohort, study variables, and statistical analyses are included in the eMethods in the Supplement. All statistical analysis was performed in SAS version 9.4 (SAS Institute). ResultsThis study included 24 915 patients with IHCA from 286 hospitals who had a mean (SD) age of 64.7 (15.2) years. There were 9848 women (39.5%) and 15 066 men (60.5%), with sex missing for 1 patient. In terms of race and ethnicity, 6170 patients (24.8%) were Black, 15 223 (61.1%) were White, 949 (3.8%) were of other race or ethnicity (American Indian or Alaska Native, Asian or Pacific Islander, and other races and ethnicities), and 2573 (10.3%) were of unkown race or ethnicity. A suspected or confirmed COVID-19 infection was present in 5916 patients (23.7%). Patients with COVID-19 were younger, more frequently men and of Black race, and more likely to have an initial
Nearly 1 in 8 patients with an IHCA has a recurrent IHCA, and these patients have worse outcomes than patients with only a single IHCA and those with an IHCA after being hospitalized for an OHCA. Despite worse survival, rates of DNAR and withdrawal of care were lowest for patients with recurrent IHCA. These findings provide important prognostic information for clinicians caring for patients with recurrent IHCA and suggest the need to better align resuscitation and end-of-life decisions with patients' prognoses after IHCA.
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