Elsevier

Resuscitation

Volume 62, Issue 3, September 2004, Pages 275-282
Resuscitation

A comparison of Antecedents to Cardiac Arrests, Deaths and EMergency Intensive care Admissions in Australia and New Zealand, and the United Kingdom—the ACADEMIA study

https://doi.org/10.1016/j.resuscitation.2004.05.016Get rights and content

Abstract

Many patients have physiological deterioration prior to cardiac arrest, death and intensive care unit (ICU) admission, that are detected and documented by medical and nursing staff. Appropriate early response to detected deterioration is likely to benefit patients. In a multi-centre, prospective, observational study over three consecutive days, we studied the incidence of antecedents (serious physiological abnormalities) preceding primary events (defined as in-hospital deaths, cardiac arrests, and unanticipated ICU admissions) in 90 hospitals (69 United Kingdom [UK]; 19 Australia and 2 New Zealand [ANZ]). 68 hospitals reported primary events during the three-day study period (50 United Kingdom, 16 Australia and 2 New Zealand).

Data on the availability of ICU/HDU beds and cardiac arrest teams and Medical Emergency Teams were also collected. Of 638 primary events, there were 308 (48.3%) deaths, 141 (22.1%) cardiac arrests, and 189 (29.6%) unplanned ICU admissions. There were differences in the pattern of primary events between the UK and ANZ (P < 0.001). There were proportionally more deaths in the UK (52.3% versus 35.3%) and a higher number of unplanned ICU admissions in ANZ (47.3% versus 24.2%). Sixty percent (383) of primary events had a total of 1032 documented antecedents. The most common antecedents were hypotension and a fall in Glasgow Coma Scale. The proportion of ICU/HDU to general hospital beds was greater in ANZ (0.034 versus 0.016, P < 0.001) and medical emergency teams were more common in ANZ (70.0% versus 27.5%, P = 0.001). The data confirm antecedents are common before death, cardiac arrest, and unanticipated ICU admission. The study also shows differences in patterns of primary events, the provision of ICU/HDU beds and resuscitation teams, between the UK and ANZ. Future research, focusing upon the relationship between service provision and the pattern of primary events, is suggested.

Sumàrio

Muitos doentes têm deteriorações fisiológicas, detectadas e documentadas pelo pessoal médico e de enfermagem, antes da paragem cardı́aca, da morte e da admissão na unidade de cuidados intensivos (ICU). A correcção precoce e apropriada das deteriorações detectadas deve beneficiar os doentes. Num estudo observacional multicêntrico, prospectivo, durante três dias consecutivos, estudamos a incidência de antecedentes (anomalias fisiológicas graves) que precederam eventos primários (definidos como mortes intra-hospitalares, paragens cardı́acas e, admissões imprevistas na ICU) em 90 hospitais (69 no Reino Unido (UK); 19 na Austrália e 2 na Nova Zelândia (ANZ)). 68 hospitais registaram eventos primários durante o perı́odo de estudo de 3 dias (50 Reino Unido, 16 Austrália e 2 na Nova Zelândia).

Também foram recolhidos dados sobre a disponibilidade de camas ICU/HDU e de equipas de emergência e de equipas de paragem cardı́aca. De 648 eventos primários, houve 308 mortes (48.3%), 141 paragens cardı́acas (22.1%) e 189 (29.6%) admissões imprevistas na ICU. Existiram diferenças no padrão de eventos primários entre o UK e a ANZ (P<0.001). Proporcionalmente houve mais mortes no UK (52.3% versus 35.3%) e um número maior de admissões não planeadas na UCI na ANZ (47.3% versus 24.2%). Sessenta por cento (383) dos eventos primários tiveram um total de 1032 antecedentes documentados. Os antecedentes mais frequentes são a hipotensão e uma diminuição na escala de coma de Glasgow. A proporção de camas ICU/HDU em relação ás camas genéricas do hospital era maior na ANZ (0.034 versus 0.016, P<0.001) e as equipas médicas de emergência eram mais comuns na ANZ (70.0% versus 27.5%, P=0.001). Os dados confirmam que os antecedentes são comuns antes da morte, da paragem cardı́aca e da admissão imprevista na ICU. O estudo também mostra diferenças no padrão de eventos primários, na disponibilidade de camas ICU/HDU e de equipas de emergência entre o Reino Unido e a Austrália e Nova Zelândia. È sugerida investigação adicional focando a relação entre o fornecimento de serviços e o padrão dos eventos primários.

Resumen

Muchos pacientes tienen deterioro psicológico previo al paro cardı́aco, muerte y admisión a unidad de cuidados intensivos (ICU), detectado y documentado por el personal médico y de enfermerı́a. Es probable que una respuesta temprana y apropiada al deterioro detectado beneficie a los pacientes. En un estudio multicéntrico, prospectivo, observacional a lo largo de tres dı́as consecutivos, estudiamos la incidencia de antecedentes (anormalidades sicológicas serias) que preceden hechos primarios (definidos como muertes intra hospitalarias, paros cardı́acos, y admisiones en ICU no anticipadas) en 90 hospitales (69 Reino Unido[UK]; 19 en Australia y 2 en Nueva Zelandia [ANZ]. 68 hospitales reportaron eventos primarios durante el perı́odo de tres dı́as de estudio (50 UK, 16 Australia y 2 en Nueva Zelandia). Se recogieron también datos acerca de la disponibilidad de camas ICU / HDU y equipos de paro cardı́aco y Equipos de Emergencias Médicas. De los 638 eventos primarios, 308 (48.3%) fueron muertes, 141 (22.1%) paros cardı́acos, y 189 (29.6%) admisiones a ICU no planificadas. Hubo diferencias en el patrón de eventos primarios entre UK y ANZ (P < 0.001). Hubo proporcionalmente mas muertes en UK (52.3% versus 35.3%) y mayor número de admisiones a ICU no planificadas en ANZ (47.3% versus 24.2%). El 60% (383) de los eventos primarios tubo un total de 1032 antecedentes documentados. Los antecedentes mas frecuentes fueron hipotensión y caı́da en la escala de coma de Glasgow. La proporción de camas ICU /HDU a camas de salas generales fue mayor en ANZ (0.034 versus 0.016, P < 0.001) y los equipos de emergencias médicas fueron mas comunes en ANZ (70% versus 27.5%, P = 0.001). Los datos confirman que los antecedentes son comunes antes de muerte, paro cardiaco, y admisión inesperada a ICU. El estudio también muestra diferencias en los patrones de eventos primarios, la provisión de camas ICU/HDU y equipos de resucitación, entre UK y ANZ. Se sugiere nueva investigación, enfocada hacia la relación entre la provisión de servicio y el patrón de eventos primarios.

Introduction

There is increasing interest in potentially preventable causes of in-hospital morbidity and mortality [1], [2], [3], [4]. Evidence suggests that the management of many critically ill patients can be improved with the result that some cardiac arrests, deaths and intensive care unit (ICU) admissions may be avoided [5], [6], [7], [8]. Prior to cardiac or respiratory arrest up to 84% of patients have significant physiological deterioration, much of which is detected and documented by medical and nursing staff [8], [9]. Often insufficient action is taken, despite up to 60% of arrests on general hospital wards having potentially correctable antecedent events, such as hypoxia and hypotension [9]. Inadequate care is also reported prior to intensive care admission and leads to increased hospital mortality [6], [7]. One study has demonstrated that patients admitted to an ICU from a general ward have a higher rate of serious physiological abnormalities than those from the emergency department or operating room [10].

In recent years there has been an attempt to improve the identification and management of critically ill patients. For example, in Australia, the Medical Emergency Team [11] has been developed to facilitate rapid and appropriate treatment for patients who are at risk of, or have established, critical illness. In the UK, a national reorganisation of critical care services has been encouraged [12] leading to the development of outreach [13] and Patient At Risk Teams [14]. There have also been educational initiatives, e.g. the ALERT™ course [15], to improve multi-professional knowledge, skills and attitudes concerning the management of critically ill patients. However, differences exist in the resources and methods used in these healthcare systems. To date, there is no published, comparative, international data on the incidence of antecedents to cardiac arrests, deaths and emergency ICU admissions and their relationship to such processes.

Section snippets

Methods

This study was an international, multi-centre, prospective, observational study, enrolling hospitalised patients aged ≥ 16 years who suffered a cardiac arrest, died, or had an unplanned admission to an ICU. Planned elective surgical admissions and patients transferred from other hospitals and ICUs were excluded. In the UK, invitations to participate in the study were sent to the intensive care unit (ICU) directors or linkmen of all hospitals with an ICU listed in the UK Intensive Care Society

Results

In the UK, 69 hospitals enrolled in the study, although only 50 reported primary events during the study period. In Australia, 19 hospitals were enrolled and 16 reported primary events. Two hospitals from New Zealand participated in the study and reported primary events. Australian and New Zealand data were grouped together and are, hereafter, referred to as ANZ. For hospitals that reported their number of acute beds, the mean number (±SD) of hospital beds was 629 ± 252 (UK, N = 62) and 474 ±

Discussion

This three-day “snap-shot” of acute care has examined the incidence of serious physiological abnormalities preceding cardiac arrests, deaths and unanticipated ICU admissions in participating hospitals in the UK, Australia and New Zealand. Serious physiological abnormalities were documented to be present in 60%. This study produces the first and largest multi-centre, international, prospective report of antecedents to death, cardiac arrest and ICU admission.

We identified significant differences

Conclusions

We have confirmed previous findings that antecedents to death, cardiac arrest and unanticipated ICU admission are common and have identified differences in the pattern of these primary events between the UK and ANZ. In the UK, cardiac arrest appears to be more common and, as this is a devastating event with a poor outcome [16], further assessment of preventative strategies are warranted. We have also shown differences in the availability of ICU/HDU beds and medical emergency teams, each of

Acknowledgements

The authors wish to thank Simon Finfer, Royal North Shore Hospital, Sydney, Chairman ANZICS CTG, the clerical staff of the ICS (UK), Jack Chen, Senior Research Fellow, Tuan Nguygen, Senior Research Fellow, and Daniel Brown, Manager, the Simpson Centre for Health Services Research, Sydney for their help with this study.

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