Cardiac arrests of hospital staff and visitors: Experience from the national registry of cardiopulmonary resuscitation

Abstract

Aim of the study

Approximately 750,000 in-hospital cardiac arrests occur annually in the United States. Many will occur to visitors or staff members within the hospital's public areas. We sought to provide a descriptive analysis of visitor cardiac arrests in hospitals and to compare survival outcomes to matching inpatient arrests.

Methods

We queried the National Registry of Cardiopulmonary Resuscitation (NRCPR^®) for all adult cardiac arrests from January 2000 to May 2006 that occurred to visitors or employees anywhere within the hospital. Visitors were matched to inpatient cardiac arrests from within the same NRCPR database for age, gender, race, prior residence and functional status, and presenting rhythms. The compared outcomes were return of spontaneous circulation (ROSC), survival to 24 h (S24), and survival to discharge (SHD).

Results

147 visitors suffered a cardiac arrest during the study period. S24 (48% vs. 37%, p = 0.011) and SHD (42% vs. 24%, p < 0.0001) were both higher in the visitor cohort. However, ROSC did not significantly differ between visitors and controls (57% vs. 51%). Visitor cardiac arrests occurred in a wide variety of locations.

Conclusion

Cardiac arrest among hospital visitors is a relatively common event. The survival outcomes of hospital visitors compared unfavorably to that of recently published experience with out-of-hospital cardiac arrest victims.

Introduction

Approximately 750,000 in-hospital cardiac arrests occur annually in the United States alone.¹ An estimated 1–4% of these arrests will occur to non-patients, specifically visitors or staff.2, 3 Modern hospitals typically sprawl over massive campuses and can essentially be miniature cities unto themselves. They provide a wide spectrum of services from intensive care to outpatient clinics to administrative offices and even retail shopping.4, 5 Outpatient clinics, often built around the main hospital campus, are among the most frequent sites of “out-of-hospital” cardiac arrests.6, 7 Many arrests occur within the hospital's public areas such as the waiting areas, gift shops, lobbies, or food courts where medical staff and equipment are not readily present.8, 9, 10

One would expect that presumably healthier hospital visitors and staff would enjoy better survival outcomes after cardiac arrest than inpatients within the same building.1, 11 However, this may not be the case.12, 13 Cardiac arrest response may actually be slower for a hospital visitor when compared to public arrests in other high-traffic buildings such as airports, casinos, or schools.14, 15, 16, 17 One small study suggests that response time to cardiac arrest situations in public areas of the hospital can indeed be much slower than for inpatients in the same hospital.⁹

Both The Joint Commission guidelines and legal considerations such as the Emergency Medical Treatment and Active Labor Act (EMTALA) specifically obligate hospitals to effectively respond to this unique circumstance of in-hospital cardiac arrest.5, 18, 19 The Joint Commission states that “Resuscitation services (must be) available throughout the hospital.” EMTALA explicitly outlines the responsibilities of hospitals to provide emergency medical services to all patients “within the hospital.” Even when not physically located in the main hospital building, hospitals must provide screening and emergency stabilization for any medical condition. In 2000, the US Centers for Medicare & Medicaid Services expanded this responsibility to any emergency on hospital property inside the “250-yard rule” by obligating the hospital to either immediately arrange transport of the stricken individual to the emergency department or to “send out a crash team of physicians and nurses to the individual on site.”¹⁹ These cardiac arrest victims have not yet been adequately described on a large scale. For instance, the typical visitor to a hospital may also be qualitatively different (perhaps sicker or older) than a visitor to a conventional public building.14, 15 Proper planning for cardiac arrest team response makes this data imperative.