American Journal of Emergency Medicine 43 (2021) 7-11

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American Journal of Emergency Medicine

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A comparison of in-hospital cardiac arrests between a United States and United Kingdom hospital

Lauren E. Powell, BA ^a,?, William J. Brady, MD ^b, Robert C. Reiser, MD ^b, Daniel J. Beckett, MBChB ^c

^a Virginia Commonwealth University School of Medicine, Richmond, VA 23298, United States of America

^b Department of Emergency Medicine, University of Virginia, Charlottesville, VA 22908, United States of America

^c Department of Acute Medicine, Forth Valley Royal Hospital, Larbert, Stirlingshire, United Kingdom

1. Introduction

Cardiac arrest may be attributed to heart Rhythm disturbances, drugs, poisoning, pre-existing heart disease, traumatic injury, coagulop- athies, respiratory arrest, and anaphylaxis, amidst others [1]. Within 4-5 min of circulation cessation, neurons in the brain and myocytes within the heart begin dying, resulting in brain damage and eventually, death [2,3]. Cardiopulmonary resuscitation (CPR), if administered within the first minutes of cardiac or respiratory arrest, can be a life- saving technique allowing for continued circulation of oxygenated blood to vital organs [4,5]. Additionally, a defibrillator may be used to restore the heart to a natural rhythm when an electrical disturbance caused the arrest to take place [5]. Decisions to resuscitate in the hospi- tal setting must be made without delay to maximize chance of survival [5]. However, survival from resuscitation to discharge remains low, esti- mated at 8.8 - 25.0% for in-patient cardiac arrests [6,7,27].

Many hospitals are pursuing earlier conversations with the patient or surrogate decision maker regarding patient preferences surrounding resuscitation measures and to the extent resuscitation would be desired [8,9]. If the patient does not desire resuscitation, a Do Not Resuscitate (DNR) form in the United States (US), or in the United Kingdom (UK), Do Not Attempt CPR (DNACPR) may be signed [8,9]. In the UK, there has been a movement to increase these early conversations to discuss goals of care and the acceptable health status for the individual patient, rather than centering around specific treatments such as CPR [8]. Rec- ommended Summary Plan for Emergency Care and Treatment (Re- SPECT) was created by the Resuscitation Council UK in 2017 [10,11]. ReSPECT is used to detail patient wishes for clinical care in future emer- gencies where they do not have capacity to make or express these wishes and includes DNACPR [12]. While both the US and UK require conversations with the patient or surrogate decision maker about a de- cision not to resuscitate, medical providers in the UK may decide not to resuscitate even if this decision may go against patient wishes on the grounds of medical futility or inappropriate CPR attempt [13-16]. Pre- dictors of poor resuscitation outcomes include patient age, underlying illness such as malignancy, congestive heart failure, pneumonia,

* Corresponding author at: P.O. Box 800699, Charlottesville, VA 22908-0699, United States of America.

E-mail address: [email protected] (L.E. Powell).

homebound status, and acute findings such as hypotension, sepsis, and elevated serum creatinine [17]. In the United States, resuscitation is the default position, where CPR is attempted unless otherwise legally specified that it has been refused by the patient or surrogate [9,18,19]. Many studies have examined survival rates and effectiveness of cardiopulmonary resuscitation (CPR) and other forms of resuscita- tion in order to improve patient care and outcomes [20-23]. Data col- lected in 2013 by the American Heart Association reveals an overall In-hospital CPR survival rate of 23.1% for adults [7]. In the United Kingdom, the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) report is a confidential study conducted each year to review care of patients across all specialties. The NCEPOD re- ports a 15% chance of survival following resuscitation, with patients often sustaining chronic disability following the cardiac event [23]. The committee for NCEPOD states that physicians have a duty to up- hold the best interests of the patient; however, it is specified that this does not necessarily mean to administer CPR to all patients who un- dergo cardiac arrest. There has also been discussion surrounding the possibility of renaming DNACPR in the UK to “Allow natural death ” or “Allow Dignified Death (ADD)” [23]. The aim of renaming is to reframe the perception that Do Not Resuscitate orders are with- holding care, and rather, the orders provide guidance that allows

dying to take place in a comfortable medical setting [23].

Given the difference in medical decision making surrounding cardio- pulmonary resuscitation in the United States and United Kingdom, this study aims to examine Incidence of cardiac arrests, resuscitation at- tempts, and immediate survival outcomes between the two hospital systems. The goal of this study is to contribute to greater knowledge sur- rounding differences between these two unique hospital systems with varied legal and financial frameworks. The study was approved by the institutional review board (IRB) at the University of Virginia and Infor- mation Governance at Forth Valley Royal Hospital.

1. Methods
   1. Data selection

Data was collected from in-patient clinical data repositories from Jan- uary 2014 to September 2015 from Forth Valley Royal Hospitalin Larbert, Scotland and the University of Virginia Hospital in Charlottesville,

https://doi.org/10.1016/j.ajem.2021.01.005

0735-6757/(C) 2021

Table 1

Forth Valley Royal Hospital Cardiac Arrest Data Summary

	Total In-hospital admissions	Total cardiac arrests	Total DNACPR	Total CPR attempts	Total deaths after CPR	Incidence of CPR	Immediate survival rate
2014	37,367	100	2	91	50	93.0%	47.3%
2015	27,503	78	1	74	42	96.2%	44.6%
Total	64,870	178	3	165	92	94.5%	45.1%

DNACPR, Do Not Attempt Cardiopulmonary Resuscitation; CPR, Cardiopulmonary Resuscitation.

Virginia. These two hospital systems were chosen given similarities in size, populations served, and classification as acute care centers. Forth Valley Royal Hospitalisanacutecarecenter thatispartof National Health Service (NHS) Forth Valley, a health board serving approximately 300,000 people [24]. There are 25 wards, 16 operating theaters, and ap- proximately 500 beds(excludingdayunits) withinthehospital[24]. Uni- versity of Virginia Hospital is a Level 1 Trauma Center in Virginia, United States, with 29 Operating rooms and 608 beds, with a large catchment area within central Virginia [25].

Patients of all ages were included in this study. Data from Forth Val- ley Royal Hospital excludes patients in the emergency department and intensive care unit, as this is not routinely or consistently collected within the data repository at that hospital. Data from the UVA emer- gency department was excluded as patients who enter the emergency department are not always coded to specify whether the cardiac arrest occurred within or outside of the hospital. Information was collected on incidence of cardiac arrest with or without attempted resuscitation, de- fined by individuals receiving chest compression(s) and/or defibrilla- tion [20]. Outcomes of the resuscitation were recorded, with survival defined as death or return to spontaneous circulation immediately post resuscitation attempt. To navigate coding at Forth Valley Royal and analyze the difference in what was categorized as successful resus- citations, calculations were based on percentages of patients whose des- tination following the cardiac event was not the mortuary.

• 1. Statistical analysis

Using the statistical analysis software RStudio (RStudio, PBC, Boston, MA) [26], a two-sample test for equality of proportions without conti- nuity correction was performed for both incidence of resuscitation attempts and immediate survival rates. A Chi-squared value was gener- ated and the P-value was tested at an alpha level of 0.05 with a 95% con- fidence interval (CI). Averages and standard deviations were calculated using Microsoft Excel Version 16.35 (Microsoft Corporation One Microsoft Way Redmond, WA). Unless specified, data are reported as means +- Standard Deviation (SD).

1. Results

A total of 178 in-patient cardiac arrest were recorded for Forth Valley Royal Hospital, with 64,870 total in-patient admissions from January 2014 to September 2015 (Table 1). 165 of the 178 cardiac arrest patients received a resuscitation attempt at Forth Valley Royal Hospital. At the UVA Hospital, a total of 541 cardiac arrests took place with a total of 48,531 in-hospital admissions included in the study time frame (Table 2). A total of 381 patients at UVA underwent a resuscitation attempt.

The analysis revealed 2.74 cardiac arrests per 1000 in-hospital ad- missions at the Forth Valley Royal Hospital between January 2014 and September 2015. Of the 178 patients included, 165 of the patients re- ceived CPR and/or defibrillation and 76 (45.1%) survived immediately after the resuscitation attempt. Only 3 of the 178 cardiac arrest patients had a DNACPR form recorded, and 10 patients without a DNACPR form also did not receive CPR at all. This corresponds to a total of 92.7% of the patients undergoing a resuscitation attempt, including patients with a DNACPR form. There was a 94.5% resuscitation attempt rate for patients that did not have a DNACPR form already filled out. Forth Valley Royal Hospital had an overall 45.1% +- 1.9% immediate survival rate for pa- tients that underwent a resuscitation attempt.

At the UVA Hospital, data revealed an average of 11.0 cardiac arrests per 1000 in-hospital patients between January 2014 and September 2015 (Tables 2 and 3). Of the 541 patients that had a cardiac arrest, 203 patients had a DNR form, and 5 of the patients were classified under “sudden or unattended death,” and thus, did not receive CPR. 99.9% of the patients without a DNR in place at the time of cardiac arrest received CPR. The notable exception was a patient that could not receive CPR due to his current physical condition, and the physician noted this reason for not having received chest compressions. Of the 381 patients undergoing a resuscitation attempt, 124 of the patients survived, corre- sponding to a 32.5% +- 5.0% survival rate. It should be noted that a small number of patients who received CPR were later switched to DNR sta- tus, and that is why the CPR attempt number and DNR number do not add up to the total number of cardiac arrests.

Table 2

University of Virginia Hospital Cardiac Arrest Data Summary

	Total In-hospital admissions	Total cardiac arrests	Total DNR	Total CPR attempts	Total deaths after CPR	Incidence of CPR	Immediate survival rate
2014	27,315	317	116	258	180	99.9%	30.2%
2015	21,216	224	87	123	77	100%	37.3%
Total	48,531	541	203	381	257	99.9%	32.5%

DNR, Do Not Resuscitate; CPR, Cardiopulmonary Resuscitation.

Table 3

Resuscitation Attempts and CPR Survival Rate Comparison from January 2014 - September 2015

	Forth Valley Royal	UVA		Forth Valley Royal	UVA
Resuscitation Attempt	165	381	Survived CPR	76	124
No Resuscitation Attempt	13	1	Total Deaths	89	257

UVA, University of Virginia Hospital; CPR, Cardiopulmonary Resuscitation.

With DNR and DNACPR patients excluded, CPR attempts between the Forth Valley Royal Hospital and UVA Hospital revealed statistical significance, with incidence of attempts at Forth Valley Royal Hospital at 94.5% and 99.9% at the UVA Hospital (X²=35.2, P = .001, CI 16.5-28.1). The CPR success rate at Forth Valley Royal Hospital demon- strated 45.1% immediate survival. At UVA, the immediate survival rate was 32.5%, also statistically significant from the survival rate at Forth Valley Royal Hospital (X²=12.93, P = .001, CI 8.21-27.6).

1. Discussion

Approximately 290,000 in-patient cardiac arrests occur in the United States each year [27]. In the United Kingdom, there is an esti- mated cardiac arrest incidence of 1-5 per 1000 hospital admissions [28]. Decades of advocacy to improve treatment has resulted in stan- dardization of cardiac arrest protocols; however, morbidity and mortal- ity following resuscitation remains low [29]. For the small percentage of patients who do survive resuscitation, neurologic and functional out- comes are often poor [29]. Prior studies have attempted to predict risk factors for Resuscitation success, revealing associations with coagulopa- thy, Glasgow Coma Score <=8 points, hypotension, shock, high Injury Se- verity Score as some of the strongest predictors [30,31]. Hospitals are advocating for early patient discussions surrounding quality of life, goals of care, and resuscitation status [32]. When a cardiac arrest does occur, medical providers in the United Kingdom have ultimate legal au- thority to decide whether resuscitation is attempted [15]. This study aims to analyze and compare incidence of cardiac arrests and resuscita- tion attempts within a United Kingdom and United States hospital sys- tem, as well as immediate Survival outcomes. This knowledge may be used to assess how differing legal, ethical, and financial frameworks within these two medical systems may affect resuscitation, as well as encourage end-of-life planning and discussions for patients.

Both Forth Valley Royal and UVA hospitals incorporate similar proce- dures and standards of care in the event of cardiac arrest. Chest compres- sions are performed at a rate of 100-120 compressions per minute at a depth of at least 2 in. for the average adult, avoiding excessive compres- sions at a depth greater than 2.4 in. [20,33,34]. Once CPR is started with the addition of oxygen and airway adjuncts, defibrillation is attempted if appropriate. Rhythm control may be achieved through supplemental

medications such as amiodarone, lidocaine, and atropine and blood pres- sure control through dopamine or epinephrine administration [35]. Re- versible causes of cardiac arrest should be sought and treated, including hypervolemia, hypoxia, acidosis, hypo- or hyperkalemia, hypothermia, Tension pneumothorax, cardiac tamponade, toxins, and pulmonary or Coronary thrombosis [36]. Both hospitals do not attempt resuscitation for a patient who has suffered irreversible death as upheld by standard- ized treatment guidelines [15,37]. However, despite the uniform resusci- tation algorithms, there was a significant difference in the number of attempts and resuscitation outcomes between the two hospital systems. Immediate cardiopulmonary resuscitation outcomes were statisti- cally significant, with a 45.1% survival rate for Forth Valley Royal Hospi- tal and 32.5% for UVA (P = .001). Additionally, a greater incidence of cardiac arrests were observed at the UVA Hospital (11.0 per 1000 in- patient population) in comparison to Forth Valley Royal (2.74 per 1000). Both incidence of cardiac arrests and survival rates may be ex- plained by differences in the population of patients being resuscitated at Forth Valley Royal Hospital and emphasis of early DNACPR decisions in Scotland. For resuscitation outcomes, the higher survival rate at Forth Valley Royal Hospital may be explained by a higher likelihood of sur- vival for patients who undergo resuscitation attempts. United Kingdom medical providers are legally protected from attempting re- suscitation on a patient by which the attempt would likely be unsuc- cessful, as described in the 2010 NHS Scotland report on DNACPR [14]. However, it is important to note that when possible, physicians will at- tempt to honor the desires of the patient when deemed possible and ap- propriate [14]. Conditions that would result in low Probability of survival are communicated to providers through a code status entered in the electronic medical records for emergency situations. The medical provider is able to assess the potential outcome of a resuscitation at- tempt for each individual patient and make an informed decision. Addi- tionally, proactive, early DNACPR decision making in the UK may also result in a lower rate of documented cardiac arrests, as those with DNACPR in place will not have a cardiac arrest coded in the electronic medical system [10-12]. In contrast to the United Kingdom, physicians in the United States must attempt resuscitation for each patient under- going cardiac arrest who does not have a DNR in place as supported by the 1991 Patient Self-Determination Act [38]. This may result in patients with lower likelihood of survival and a pre-existing poor health status,

Fig. 1. A comparison of All-Cause In-Patient Mortality between the University of Virginia (UVA) and Forth Valley Royal Hospital (FVRH) during the January 2014-September 2015 study time frame. The UVA mortality rate during the study time frame was 3.5% in comparison to FVRH at 2.9% for all inpatient admissions. Total cardiac arrest events and cardiac arrest mortality during the study time frame are also shown in the figure. UVA, University of Virginia; FVRH, Forth Valley Royal Hospital.

but do not have a DNR in place, to undergo a resuscitation attempt. Other potential explanations for outcome differences are differences in the severity of patient health status. This can be measured using a case-mix index (CMI). For the UVA hospital, the CMI is 2.5. Forth Valley publishes an annual report on Standardized Mortality Ratio (SMR), comparing actual deaths and expected deaths within 30 days, similar to the CMI provided by UVA. During the time period of this study, the SMR ranged from 0.89-1.0, suggesting a lower patient illness severity in comparison to the UVA Hospital [39] and subsequently may also con- tribute to explaining the difference in outcomes between the hospital systems.

A literature search and post-hoc data review was performed to ex- amine other variables, including length of stay and total mortality rates. In a 2017 study by Beckett et al., length of stay across 4 boards within NHS Scotland was analyzed between January 2015 to July 2016. In 2015, the time of this study, the average length of stay for spe- cialty and general medicine patients ranged from 5.6-7.3 days [40]. In comparison, length of stay at the UVA Hospital ranged from 6.33-6.71 over 2018-2020 [41]. Mortality of all hospital patients at UVA was 873 in 2014 and 846 in 2015 (approximately 3.5% of in-patient admissions in the study time frame) [42]. Mortality of patients at Forth Valley, ob- tained through a post-hoc review, was 1031 in 2014 and 843 between January to September 2015 (2.9% of total in-patient admissions). Thus, while length of stay was similar between the two sites, there was a slightly higher mortality rate of patients at UVA Hospital (Fig. 1). There was also a greater number of deaths attributed to cardiac arrest at the UVA Hospital compared to Forth Valley (254 deaths versus 89 deaths during the study time frame); similarly, the case-mix index sug- gests patient illness severity is higher at the UVA Hospital and may con- tribute to the higher mortality rates in this patient population for both cardiac arrest and non-cardiac arrest causes. These differences between patient populations is another potential explanation for the variance in resuscitation outcomes.

Additionally, the number of resuscitation attempts varied signifi-

cantly between Forth Valley Royal and UVA hospitals. There was a 94.3% attempt rate at Forth Valley Royal Hospital and a 99.9% attempt rate at UVA (P = .001). The 94.3% attempt rate at Forth Valley Royal, with patients with DNACPR excluded, reveals that 5.7% patients who did not have a DNACPR in place did not undergo a resuscitation attempt. At the UVA Hospital, 0.01% of cardiac arrest patients without a DNR form did not receive resuscitation, with the 0.01% notable for a physical con- traindication to receiving chest compressions. The difference in these numbers may be explained by the legal authority of medical providers in the United Kingdom to defer resuscitation in a patient with high like- lihood of mortality regardless of the medical intervention. Also notable in the analysis was the number of DNACPR forms in place at Forth Valley Royal Hospital. While the data revealed only 3 DNACPR patients, as mentioned prior, most patients with a DNACPR in place at Forth Valley Royal Hospital will not have a cardiac arrest code alerted in the elec- tronic medical system and thus, were not included in the analysis. This likely explains the difference between the amount of DNR and DNACPR forms in these two hospital systems.

Both the United Kingdom and the United States aim to increase early patient conversations about resuscitation, particularly among severe or terminally ill patients [8,23]. Increasing these end-of-life and quality of life conversations are important to setting realistic expectations among patients and family members prior to a cardiac event [13]. These discussions should be centered around perceptions of resuscita- tion methods such as CPR, desires for functional status, and what quality of life means to each individual patient [13]. Increasing these conversa- tions, particularly among patients with poor health status and low like- lihood of resuscitation survival, may influence how resuscitation success rates in both hospital systems are reported.

Limitationsofthisstudyincludelackofresuscitationoutcomedatabe- yond immediate survival as this was not available for data analysis. Thus, survival to discharge may vary between the two hospital systems but

could not be compared in this study, limiting the applicability of the study to long-term outcomes. Additional factors that may contribute to the observed differences of these two sites include interpretations of eth- ical frameworks and financial and health system structures between the two hospital systems [43,44]. Future studies may further explore how these ethical frameworks and financial systems may contribute to medi- cal decision making in these different political and geographic locations, as well as exploring long-term survival rates following resuscitation.

1. Conclusion

The incident rate of resuscitation attempts between the United Kingdom and United States hospital systems in this study were statisti- cally significant, with the UVA hospital undergoing a greater number of attempts but with a lower immediate survival rate. Landmark legal acts, specifically the 1991 Patient Self-Determination Act in the U.S. and the 2010 NHS Scotland Report in Scotland have determined the extent by which medical providers in these systems may respond to cardiac arrest [14,38]. Both systems advocate for increasing conversations surround- ing end-of-life preferences and care, with discussions highlighting qual- ity of life and perceptions of resuscitation to better serve patients at each hospital system [8,9].

Sources of support

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Date of presentation

Powell LE, Brady WJ, Reiser RC, Beckett DJ. A Comparison of Inci- dence and Outcome of In-Hospital Cardiac Arrests Between a United States and United Kingdom Hospital System. American College of Emer- gency Physicians 2020 Research Forum. October 26-29, 2020. Virtual Meeting.

Credit authorship contribution statement

Lauren E. Powell: Writing - original draft, Writing - review & editing. William J. Brady: Writing - original draft, Writing - review & editing. Robert C. Reiser: Writing - original draft, Writing - review & editing. Daniel J. Beckett: Writing - original draft, Writing - review & editing.

Declaration of Competing Interest

The authors of this study have no relevant financial or nonfinancial relationships to disclose.

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