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IMPORTANCE: The administration of a high fraction of oxygen following return of spontaneous circulation in out-of-hospital cardiac arrest may increase reperfusion brain injury. OBJECTIVE: To determine whether targeting a lower oxygen saturation in the early phase of postresuscitation care for out-of-hospital cardiac arrest improves survival at hospital discharge. DESIGN, SETTING, AND PARTICIPANTS: This multicenter, parallel-group, randomized clinical trial included unconscious adults with return of spontaneous circulation and a peripheral oxygen saturation (Spo(2)) of at least 95% while receiving 100% oxygen. The trial was conducted in 2 emergency medical services and 15 hospitals in Victoria and South Australia, Australia, between December 11, 2017, and August 11, 2020, with data collection from ambulance and hospital medical records (final follow-up date, August 25, 2021). The trial enrolled 428 of a planned 1416 patients. INTERVENTIONS: Patients were randomized by paramedics to receive oxygen titration to achieve an oxygen saturation of either 90% to 94% (intervention; n = 216) or 98% to 100% (standard care; n = 212) until arrival in the intensive care unit. MAIN OUTCOMES AND MEASURES: The primary outcome was survival to hospital discharge. There were 9 secondary outcomes collected, including hypoxic episodes (Spo(2)

IMPORTANCE: Hypotension is common during tracheal intubation of critically ill adults and increases the risk of cardiac arrest and death. Whether administering an intravenous fluid bolus to critically ill adults undergoing tracheal intubation prevents severe hypotension, cardiac arrest, or death remains uncertain. OBJECTIVE: To determine the effect of fluid bolus administration on the incidence of severe hypotension, cardiac arrest, and death. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial enrolled 1067 critically ill adults undergoing tracheal intubation with sedation and positive pressure ventilation at 11 intensive care units in the US between February 1, 2019, and May 24, 2021. The date of final follow-up was June 21, 2021. INTERVENTIONS: Patients were randomly assigned to receive either a 500-mL intravenous fluid bolus (n = 538) or no fluid bolus (n = 527). MAIN OUTCOMES AND MEASURES: The primary outcome was cardiovascular collapse (defined as new or increased receipt of vasopressors or a systolic blood pressure

In a large retrospective evaluation of intubation during cardiac arrest, Dr Andersen and colleagues suggested that intubation during the first 15 minutes of in-hospital cardiac arrest was associated with decreased survival.1 Although the authors tried to balance the distribution of groups with statistical analysis, the original groups were significantly different, preventing like groups from being analyzed.

Quinine has been used since the 1930s to treat idiopathic muscular cramps. However, in 2006, because of efficacy and safety issues, the US Food and Drug Administration cautioned about this off-label use of quinine, citing “665 reports of adverse events with serious outcomes…including 93 deaths.”1 Despite warnings, quinine is still prescribed to individuals with idiopathic muscular cramps. Furthermore, many drinks such as bitter lemon or tonic waters contain quinine, and hence, many may be exposed to quinine daily. This study explored the association between long-term quinine exposure and all-cause mortality.

Importance Catheter ablation is effective in restoring sinus rhythm in atrial fibrillation (AF), but its effects on long-term mortality and stroke risk are uncertain. Objective To determine whether catheter ablation is more effective than conventional medical therapy for improving outcomes in AF. Design, Setting, and Participants The Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation trial is an investigator-initiated, open-label, multicenter, randomized trial involving 126 centers in 10 countries. A total of 2204 symptomatic patients with AF aged 65 years and older or younger than 65 years with 1 or more risk factors for stroke were enrolled from November 2009 to April 2016, with follow-up through December 31, 2017. Interventions The catheter ablation group (n = 1108) underwent pulmonary vein isolation, with additional ablative procedures at the discretion of site investigators. The drug therapy group (n = 1096) received standard rhythm and/or rate control drugs guided by contemporaneous guidelines. Main Outcomes and Measures The primary end point was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. Among 13 prespecified secondary end points, 3 are included in this report: all-cause mortality; total mortality or cardiovascular hospitalization; and AF recurrence. Results Of the 2204 patients randomized (median age, 68 years; 37.2% female; 42.9% had paroxysmal AF and 57.1% had persistent AF), 89.3% completed the trial. Of the patients assigned to catheter ablation, 1006 (90.8%) underwent the procedure. Of the patients assigned to drug therapy, 301 (27.5%) ultimately received catheter ablation. In the intention-to-treat analysis, over a median follow-up of 48.5 months, the primary end point occurred in 8.0% (n = 89) of patients in the ablation group vs 9.2% (n = 101) of patients in the drug therapy group (hazard ratio [HR], 0.86 [95% CI, 0.65-1.15];P = .30). Among the secondary end points, outcomes in the ablation group vs the drug therapy group, respectively, were 5.2% vs 6.1% for all-cause mortality (HR, 0.85 [95% CI, 0.60-1.21];P = .38), 51.7% vs 58.1% for death or cardiovascular hospitalization (HR, 0.83 [95% CI, 0.74-0.93];P = .001), and 49.9% vs 69.5% for AF recurrence (HR, 0.52 [95% CI, 0.45-0.60];P Conclusions and Relevance Among patients with AF, the strategy of catheter ablation, compared with medical therapy, did not significantly reduce the primary composite end point of death, disabling stroke, serious bleeding, or cardiac arrest. However, the estimated treatment effect of catheter ablation was affected by lower-than-expected event rates and treatment crossovers, which should be considered in interpreting the results of the trial. Trial Registration ClinicalTrials.gov Identifier:NCT00911508

Importance Telemetry alarms involving traditional on-site monitoring rarely alter management and often miss serious events, sometimes resulting in death. Poor patient selection contributes to a high alarm volume with low clinical yield. Objective To evaluate outcomes associated with an off-site central monitoring unit (CMU) applying standardized cardiac telemetry indications using electronic order entry. Design, Setting, and Participants All non–intensive care unit (ICU) patients at Cleveland Clinic and 3 regional hospitals over 13 months between March 4, 2014, and April 4, 2015. Exposures An off-site CMU applied standardized cardiac telemetry when ordered for standard indications, such as for known or suspected tachyarrhythmias or bradyarrhythmias. Main Outcomes and Measures CMU detection and notification of rhythm/rate alarms occurring 1 hour or less prior to emergency response team (ERT) activation, direct CMU-to-ERT notification outcomes, total telemetry census, and cardiopulmonary arrests in comparison with the previous 13 months. Results The CMU received electronic telemetry orders for 99 048 patients (main campus, 72 199 [73%]) and provided 410 534 notifications (48% arrhythmia/hemodynamic) among 61 nursing units. ERT activation occurred among 3243 patients, including 979 patients (30%) with rhythm/rate changes occurring 1 hour or less prior to the ERT activation. The CMU detected and provided accurate notification for 772 (79%) of those events. In addition, the CMU provided discretionary direct ERT notification for 105 patients (ventricular tachycardia, n = 44; pause/asystole, n = 36; polymorphic ventricular tachycardia/ventricular fibrillation, n = 14; other, n = 11), including advance warning of 27 cardiopulmonary arrest events (26%) for which return of circulation was achieved in 25 patients (93%). Telemetry standardization was associated with a mean 15.5% weekly census reduction in the number of non-ICU monitored patients per week when compared with the prior 13-month period (580 vs 670 patients; mean difference, −90 patients [95% CI, −82 to −99]; P Conclusions and Relevance Among non–critically ill patients, use of standardized cardiac telemetry with an off-site central monitoring unit was associated with detection and notification of cardiac rhythm and rate changes within 1 hour prior to the majority of ERT activations, and also with a reduction in the census of monitored patients, without an increase in cardiopulmonary arrest events.

To the Editor The study by Dr Andersen and colleagues1 found an association between delayed administration of epinephrine and poorer survival rates after in-hospital pediatric cardiac arrest. There are at least 3 possible scenarios for delivering epinephrine: the patient might already have a functioning cannula or central line, venous access might be attempted during resuscitation, or epinephrine might be delivered by intraosseous injection. Epinephrine can be given quickly and reliably by intraosseous injection, but clinicians could preferentially attempt intravenous administration first.

After patients survive an in-hospital cardiac arrest, discussions should occur about prognosis and preferences for future resuscitative efforts.To assess whether patients' decisions for do-not-resuscitate (DNR) orders after a successful resuscitation from in-hospital cardiac arrest are aligned with their expected prognosis.Within Get With The Guidelines-Resuscitation, we identified 26,327 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest between April 2006 and September 2012 at 406 US hospitals. Using a previously validated prognostic tool, each patient's likelihood of favorable neurological survival (ie, without severe neurological disability) was calculated. The proportion of patients with DNR orders within each prognosis score decile and the association between DNR status and actual favorable neurological survival were examined.Do-not-resuscitate orders within 12 hours of ROSC.Likelihood of favorable neurological survival.Overall, 5944 (22.6% [95% CI, 22.1%-23.1%]) patients had DNR orders within 12 hours of ROSC. This group was older and had higher rates of comorbidities (all P .05) than patients without DNR orders. Among patients with the best prognosis (decile 1), 7.1% (95% CI, 6.1%-8.1%) had DNR orders even though their predicted rate of favorable neurological survival was 64.7% (95% CI, 62.8%-66.6%). Among patients with the worst expected prognosis (decile 10), 36.0% (95% CI, 34.2%-37.8%) had DNR orders even though their predicted rate for favorable neurological survival was 4.0% (95% CI, 3.3%-4.7%) (P for both trends.001). This pattern was similar when DNR orders were redefined as within 24 hours, 72 hours, and 5 days of ROSC. The actual rate of favorable neurological survival was higher for patients without DNR orders (30.5% [95% CI, 29.9%-31.1%]) than it was for those with DNR orders (1.8% [95% CI, 1.6%-2.0%]). This pattern of lower survival among patients with DNR orders was seen in every decile of expected prognosis.Although DNR orders after in-hospital cardiac arrest were generally aligned with patients' likelihood of favorable neurological survival, only one-third of patients with the worst prognosis had DNR orders. Patients with DNR orders had lower survival than those without DNR orders, including those with the best prognosis.

In Reply Dr Wilt and Ms Lee question the validity of our results due to between-group differences in baseline characteristics before propensity matching, specifically mentioning differences in noninvasive ventilation and the initial rhythm. As noted in Table 2 in the article, these characteristics were well matched in the propensity score–matched cohort. Therefore, these variables cannot confound the adjusted results. Furthermore, in our subgroup analysis according to initial rhythm, intubation was associated with poor outcomes in both those with initial shockable and nonshockable rhythms. As noted in the article, there might be unmeasured confounders we were unable to adjust for.

The effectiveness of perioperative β-blockade in patients undergoing noncardiac surgery remains controversial.To determine the associations of early perioperative exposure to β-blockers with 30-day postoperative outcome in patients undergoing noncardiac surgery.A retrospective cohort analysis evaluating exposure to β-blockers on the day of or following major noncardiac surgery among a population-based sample of 136,745 patients who were 1:1 matched on propensity scores (37,805 matched pairs) treated at 104 VA medical centers from January 2005 through August 2010.All cause 30-day mortality and cardiac morbidity (cardiac arrest or Q-wave myocardial infarction).Overall 55,138 patients (40.3%) were exposed to β-blockers. Exposure was higher in the 66.7% of 13,863 patients undergoing vascular surgery (95% CI, 65.9%-67.5%) than in the 37.4% of 122,882 patients undergoing nonvascular surgery (95% CI, 37.1%-37.6%; P.001). Exposure increased as Revised Cardiac Risk Index factors increased, with 25.3% (95% CI, 24.9%-25.6%) of those with no risk vs 71.3% (95% CI, 69.5%-73.2%) of those with 4 risk factors or more exposed to β-blockers (P.001). Death occurred among 1.1% (95% CI, 1.1%-1.2%) and cardiac morbidity occurred among 0.9% (95% CI, 0.8%-0.9%) of patients. In the propensity matched cohort, exposure was associated with lower mortality (relative risk [RR], 0.73; 95% CI, 0.65-0.83; P.001; number need to treat [NNT], 241; 95% CI, 173-397). When stratified by cumulative numbers of Revised Cardiac Risk Index factors, β-blocker exposure was associated with significantly lower mortality among patients with 2 factors (RR, 0.63 [95% CI, 0.50-0.80]; P.001; NNT, 105 [95% CI, 69-212]), 3 factors (RR, 0.54 [95% CI, 0.39-0.73]; P.001; NNT, 41 [95% CI, 28-80]), or 4 factors or more (RR, 0.40 [95% CI, 0.25-0.73]; P.001; NNT, 18 [95% CI, 12-34]). This association was limited to patients undergoing nonvascular surgery. β-Blocker exposure was also associated with a lower rate of nonfatal Q-wave infarction or cardiac arrest (RR, 0.67 [95% CI, 0.57-0.79]; P.001; NNT, 339 [95% CI, 240-582]), again limited to patients undergoing nonvascular surgery.Among propensity-matched patients undergoing noncardiac, nonvascular surgery, perioperative β-blocker exposure was associated with lower rates of 30-day all-cause mortality in patients with 2 or more Revised Cardiac Risk Index factors. Our findings support use of a cumulative number of Revised Cardiac Risk Index predictors in decision making regarding institution and continuation of perioperative β-blockade. A multicenter randomized trial involving patients at a low to intermediate risk by these factors would be of interest to validate these observational findings.

Importance Therapeutic hypothermia is used for patients following both out-of-hospital and in-hospital cardiac arrest. However, randomized trials on its efficacy for the in-hospital setting do not exist, and comparative effectiveness data are limited. Objective To evaluate the association between therapeutic hypothermia and survival after in-hospital cardiac arrest. Design, Setting, and Patients In this cohort study, within the national Get With the Guidelines–Resuscitation registry, 26 183 patients successfully resuscitated from an in-hospital cardiac arrest between March 1, 2002, and December 31, 2014, and either treated or not treated with hypothermia at 355 US hospitals were identified. Follow-up ended February 4, 2015. Exposure Induction of therapeutic hypothermia. Main Outcomes and Measures The primary outcome was survival to hospital discharge. The secondary outcome was favorable neurological survival, defined as a Cerebral Performance Category score of 1 or 2 (ie, without severe neurological disability). Comparisons were performed using a matched propensity score analysis and examined for all cardiac arrests and separately for nonshockable (asystole and pulseless electrical activity) and shockable (ventricular fibrillation and pulseless ventricular tachycardia) cardiac arrests. Results Overall, 1568 of 26 183 patients with in-hospital cardiac arrest (6.0%) were treated with therapeutic hypothermia; 1524 of these patients (mean [SD] age, 61.6 [16.2] years; 58.5% male) were matched by propensity score to 3714 non–hypothermia-treated patients (mean [SD] age, 62.2 [17.5] years; 57.1% male). After adjustment, therapeutic hypothermia was associated with lower in-hospital survival (27.4% vs 29.2%; relative risk [RR], 0.88 [95% CI, 0.80 to 0.97]; risk difference, −3.6% [95% CI, −6.3% to −0.9%]; P = .01), and this association was similar (interaction P = .74) for nonshockable cardiac arrest rhythms (22.2% vs 24.5%; RR, 0.87 [95% CI, 0.76 to 0.99]; risk difference, −3.2% [95% CI, −6.2% to −0.3%]) and shockable cardiac arrest rhythms (41.3% vs 44.1%; RR, 0.90 [95% CI, 0.77 to 1.05]; risk difference, −4.6% [95% CI, −10.9% to 1.7%]). Therapeutic hypothermia was also associated with lower rates of favorable neurological survival for the overall cohort (hypothermia-treated group, 17.0% [246 of 1443 patients]; non–hypothermia-treated group, 20.5% [725 of 3529 patients]; RR, 0.79 [95% CI, 0.69 to 0.90]; risk difference, −4.4% [95% CI, −6.8% to −2.0%]; P P = .88). Conclusions and Relevance Among patients with in-hospital cardiac arrest, use of therapeutic hypothermia compared with usual care was associated with a lower likelihood of survival to hospital discharge and a lower likelihood of favorable neurological survival. These observational findings warrant a randomized clinical trial to assess efficacy of therapeutic hypothermia for in-hospital cardiac arrest.

Approximately 160,000 U.S. patients die annually from an in-hospital cardiac arrest, yet we continue to have a poor understanding of how to improve patient survival after these events. In part, this is because cardiac arrest is an unexpected event that is difficult to predict with great certainty. Moreover, it involves heterogeneous groups of patients necessitating the engagement of numerous physician specialties, hospital floors, and allied health care personnel to improve resuscitation outcomes. Fortunately, several important epidemiological studies have provided us with new insights and opportunities for improving patient survival after cardiac arrest. Risk-adjusted survival after in-hospital cardiac arrest has significantly improved over the past decade, from 13.7% in 2000 to 22.4% in 2009.1 Yet reasons for the improvement remain fairly opaque, although factors such as delays in defibrillation,2 off-hours or unwitnessed arrests,3 and black race4 have been associated with lower survival. Furthermore, substantial variation in survival outcomes exists across hospitals,5 which suggests that some facilities may be instituting better strategies for resuscitation care. These strategies are likely to be driven by better implementation of processes of care rather than by enhanced technologies (e.g., remote intensive care unit monitoring, automated external defibrillators, controlled hypothermia), which have shown inconsistent improvements in survival.6–7 While the potential exists for great advancements in resuscitation over the next decade, the field will need to directly address 3 important knowledge gaps over the coming years that all relate to measurement of outcomes.

Automated external defibrillators (AEDs) improve survival from out-of-hospital cardiac arrests, but data on their effectiveness in hospitalized patients are limited.To evaluate the association between AED use and survival for in-hospital cardiac arrest.Cohort study of 11,695 hospitalized patients with cardiac arrests between January 1, 2000, and August 26, 2008, at 204 US hospitals following the introduction of AEDs on general hospital wards.Survival to hospital discharge by AED use, using multivariable hierarchical regression analyses to adjust for patient factors and hospital site.Of 11,695 patients, 9616 (82.2%) had nonshockable rhythms (asystole and pulseless electrical activity) and 2079 (17.8%) had shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia). AEDs were used in 4515 patients (38.6%). Overall, 2117 patients (18.1%) survived to hospital discharge. Within the entire study population, AED use was associated with a lower rate of survival after in-hospital cardiac arrest compared with no AED use (16.3% vs 19.3%; adjusted rate ratio [RR], 0.85; 95% confidence interval [CI], 0.78-0.92; P.001). Among cardiac arrests due to nonshockable rhythms, AED use was associated with lower survival (10.4% vs 15.4%; adjusted RR, 0.74; 95% CI, 0.65-0.83; P.001). In contrast, for cardiac arrests due to shockable rhythms, AED use was not associated with survival (38.4% vs 39.8%; adjusted RR, 1.00; 95% CI, 0.88-1.13; P = .99). These patterns were consistently observed in both monitored and nonmonitored hospital units where AEDs were used, after matching patients to the individual units in each hospital where the cardiac arrest occurred, and with a propensity score analysis.Among hospitalized patients with cardiac arrest, use of AEDs was not associated with improved survival.

Context Chest compression–only bystander cardiopulmonary resuscitation (CPR) may beaseffectiveasconventionalCPRwithrescuebreathingforout-of-hospitalcardiacarrest. Objective To investigate the survival of patients with out-of-hospital cardiac arrest using compression-only CPR (COCPR) compared with conventional CPR. Design, Setting, and Patients A 5-year prospective observational cohort study of survival in patients at least 18 years old with out-of-hospital cardiac arrest between January 1, 2005, and December 31, 2009, in Arizona. The relationship between layperson bystander CPR and survival to hospital discharge was evaluated using multivariable logistic regression. Main Outcome Measure Survival to hospital discharge. Results Among 5272 adults with out-of-hospital cardiac arrest of cardiac etiology not observed by responding emergency medical personnel, 779 were excluded because bystander CPR was provided by a health care professional or the arrest occurred in a medical facility. A total of 4415 met all inclusion criteria for analysis, including 2900 who received no bystander CPR, 666 who received conventional CPR, and 849 who received COCPR. Rates of survival to hospital discharge were 5.2% (95% confidence interval [CI], 4.4%-6.0%) for the no bystander CPR group, 7.8% (95% CI, 5.8%-9.8%) for conventional CPR, and 13.3% (95% CI, 11.0%-15.6%) for COCPR. The adjusted odds ratio (AOR) for survival for conventional CPR vs no CPR was 0.99 (95% CI, 0.69-1.43), for COCPR vs no CPR, 1.59 (95% CI, 1.18-2.13), and for COCPR vs conventional CPR, 1.60 (95% CI, 1.08-2.35). From 2005 to 2009, lay rescuer CPR increased from 28.2% (95% CI, 24.6%-31.8%) to 39.9% (95% CI, 36.8%-42.9%; P.001); the proportion of CPR that was COCPR increased from 19.6% (95% CI, 13.6%-25.7%) to 75.9% (95% CI, 71.7%-80.1%; P.001). Overall survival increased from 3.7% (95% CI, 2.2%-5.2%) to 9.8% (95% CI, 8.0%-11.6%; P.001). Conclusion Among patients with out-of-hospital cardiac arrest, layperson compression-only CPR was associated with increased survival compared with conventional CPR and no bystander CPR in this setting with public endorsement of chest compression–only CPR.

Context Rapid response teams have been shown in adult inpatients to decrease cardiopulmonary arrest (code) rates outside of the intensive care unit (ICU). Because a primary action of rapid response teams is to transfer patients to the ICU, their ability to reduce hospital-wide code rates and mortality remains unknown. Objective To determine rates of hospital-wide codes and mortality before and after implementation of a long-term rapid response team intervention. Design, Setting, and Patients A prospective cohort design of adult inpatients admitted between January 1, 2004, and August 31, 2007, at Saint Luke's Hospital, a 404-bed tertiary care academic hospital in Kansas City, Missouri. Rapid response team education and program rollout occurred from September 1 to December 31, 2005. A total of 24 193 patient admissions were evaluated prior to the intervention (January 1, 2004, to August 31, 2005), and 24 978 admissions were evaluated after the intervention (January 1, 2006, to August 31, 2007). Intervention Using standard activation criteria, a 3-member rapid response team composed of experienced ICU staff and a respiratory therapist performed the evaluation, treatment, and triage of inpatients with evidence of acute physiological decline. Main Outcome Measures Hospital-wide code rates and mortality, adjusted for preintervention trends. Results There were a total of 376 rapid response team activations. After rapid response team implementation, mean hospital-wide code rates decreased from 11.2 to 7.5 per 1000 admissions. This was not associated with a reduction in the primary end point of hospital-wide code rates (adjusted odds ratio [AOR], 0.76 [95% confidence interval {CI}, 0.57-1.01]; P = .06), although lower rates of non-ICU codes were observed (non-ICU AOR, 0.59 [95% CI, 0.40-0.89] vs ICU AOR, 0.95 [95% CI, 0.64-1.43]; P = .03 for interaction). Similarly, hospital-wide mortality did not differ between the preintervention and postintervention periods (3.22 vs 3.09 per 100 admissions; AOR, 0.95 [95% CI, 0.81-1.11]; P = .52). Secondary analyses revealed few instances of rapid response team undertreatment or underuse that may have affected the mortality findings. Conclusion In this large single-institution study, rapid response team implementation was not associated with reductions in hospital-wide code rates or mortality.

Context The health and policy implications of regional variation in incidence and outcome of out-of-hospital cardiac arrest remain to be determined. Objective To evaluate whether cardiac arrest incidence and outcome differ across geographic regions. Design, Setting, and Patients Prospective observational study (the Resuscitation Outcomes Consortium) of all out-of-hospital cardiac arrests in 10 North American sites (8 US and 2 Canadian) from May 1, 2006, to April 30, 2007, followed up to hospital discharge, and including data available as of June 28, 2008. Cases (aged 0-108 years) were assessed by organized emergency medical services (EMS) personnel, did not have traumatic injury, and received attempts at external defibrillation or chest compressions or resuscitation was not attempted. Census data were used to determine rates adjusted for age and sex. Main Outcome Measures Incidence rate, mortality rate, case-fatality rate, and survival to discharge for patients assessed or treated by EMS personnel or with an initial rhythm of ventricular fibrillation. Results Among the 10 sites, the total catchment population was 21.4 million, and there were 20 520 cardiac arrests. A total of 11 898 (58.0%) had resuscitation attempted; 2729 (22.9% of treated) had initial rhythm of ventricular fibrillation or ventricular tachycardia or rhythms that were shockable by an automated external defibrillator; and 954(4.6% of total) were discharged alive. The median incidence of EMS-treated cardiac arrest across sites was 52.1 (interquartile range [IQR], 48.0-70.1) per 100 000 population; survival ranged from 3.0% to 16.3%, with a median of 8.4% (IQR, 5.4%-10.4%). Median ventricular fibrillation incidence was 12.6 (IQR, 10.6-5.2) per 100 000 population; survival ranged from 7.7% to 39.9%, with a median of 22.0% (IQR, 15.0%-24.4%), with significant differences across sites for incidence and survival (P Conclusion In this study involving 10 geographic regions in North America, there were significant and important regional differences in out-of-hospital cardiac arrest incidence and outcome.

Context Occurrence of in-hospital cardiac arrest and survival patterns have not been characterized by time of day or day of week. Patient physiology and process of care for in-hospital cardiac arrest may be different at night and on weekends because of hospital factors unrelated to patient, event, or location variables. Objective To determine whether outcomes after in-hospital cardiac arrest differ during nights and weekends compared with days/evenings and weekdays. Design and Setting We examined survival from cardiac arrest in hourly time segments, defining day/evening as 7:00 AM to 10:59 PM, night as 11:00 PM to 6:59 AM, and weekend as 11:00 PM on Friday to 6:59 AM on Monday, in 86 748 adult, consecutive in-hospital cardiac arrest events in the National Registry of Cardiopulmonary Resuscitation obtained from 507 medical/surgical participating hospitals from January 1, 2000, through February 1, 2007. Main Outcome Measures The primary outcome of survival to discharge and secondary outcomes of survival of the event, 24-hour survival, and favorable neurological outcome were compared using odds ratios and multivariable logistic regression analysis. Point estimates of survival outcomes are reported as percentages with 95% confidence intervals (95% CIs). Results A total of 58 593 cases of in-hospital cardiac arrest occurred during day/evening hours (including 43 483 on weekdays and 15 110 on weekends), and 28 155 cases occurred during night hours (including 20 365 on weekdays and 7790 on weekends). Rates of survival to discharge (14.7% [95% CI, 14.3%-15.1%] vs 19.8% [95% CI, 19.5%-20.1%], return of spontaneous circulation for longer than 20 minutes (44.7% [95% CI, 44.1%-45.3%] vs 51.1% [95% CI, 50.7%-51.5%]), survival at 24 hours (28.9% [95% CI, 28.4%-29.4%] vs 35.4% [95% CI, 35.0%-35.8%]), and favorable neurological outcomes (11.0% [95% CI, 10.6%-11.4%] vs 15.2% [95% CI, 14.9%-15.5%]) were substantially lower during the night compared with day/evening (all P values

Introduction of a rapid response team (RRT) has been shown to decrease mortality and cardiopulmonary arrests outside of the intensive care unit (ICU) in adult inpatients. No published studies to date show significant reductions in mortality or cardiopulmonary arrests in pediatric inpatients.To determine the effect on hospital-wide mortality rates and code rates outside of the ICU setting after RRT implementation at an academic children's hospital.A cohort study design with historical controls at a 264-bed, free-standing, quaternary care academic children's hospital. Pediatric inpatients who spent at least 1 day on a medical or surgical ward between January 1, 2001, and March 31, 2007, were included. A total of 22,037 patient admissions and 102,537 patient-days were evaluated preintervention (before September 1, 2005), and 7257 patient admissions and 34,420 patient-days were evaluated postintervention (on or after September 1, 2005).The RRT included a pediatric ICU-trained fellow or attending physician, ICU nurse, ICU respiratory therapist, and nursing supervisor. This team was activated using standard criteria and was available at all times to assess, treat, and triage decompensating pediatric inpatients.Hospital-wide mortality rates and code (respiratory and cardiopulmonary arrests) rates outside of the ICU setting. All outcomes were adjusted for case mix index values.After RRT implementation, the mean monthly mortality rate decreased by 18% (1.01 to 0.83 deaths per 100 discharges; 95% confidence interval [CI], 5%-30%; P = .007), the mean monthly code rate per 1000 admissions decreased by 71.7% (2.45 to 0.69 codes per 1000 admissions), and the mean monthly code rate per 1000 patient-days decreased by 71.2% (0.52 to 0.15 codes per 1000 patient-days). The estimated code rate per 1000 admissions for the postintervention group was 0.29 times that for the preintervention group (95% likelihood ratio CI, 0.10-0.65; P = .008), and the estimated code rate per 1000 patient-days for the postintervention group was 0.28 times that for the preintervention group (95% likelihood ratio CI, 0.10-0.64; P = .007).Implementation of an RRT was associated with a statistically significant reduction in hospital-wide mortality rate and code rate outside of the pediatric ICU setting.

Few moments in medicine are more vividly and regularly captured in the lay media than the resuscitation response (ie, code blue) to an in-hospital cardiac arrest. However, there is concern that outcomes from resuscitation efforts are far better on television than in real life.1 Consequently, the public’s view of the implications of in-hospital cardiac arrest may be distorted, thereby complicating ensuing care planning, especially with regard to prognosis and whether to limit care or institute do-not-resuscitate (DNR) orders. In this issue of JAMA, Fendler and colleagues2 provide a comprehensive and contemporary description of what actually happens to patients who experience in-hospital cardiac arrest, focusing on those for whom resuscitation results in successful restoration of spontaneous circulation (ROSC) and whether subsequent institution of DNR orders in these patients is alignedwith their prognosis. The authors analyzed the Get With the Guidelines Resuscitation registry, a large database of in-hospital cardiac arrests at several hundred US hospitals. The analysis was limited to patients for whom there were no prearrest DNR orders and whose cardiac arrest occurred while the patient was admitted to a hospital ward or intensive care unit. For patients who achieved successful ROSC, the authors used the cardiac arrest survival post-arrest resuscitation in-hospital (CASPRI) prognostic tool to estimate the likelihood of being discharged alive without severe neurological dysfunction and then determined if and when DNR orders were instituted across deciles of risk. Among 59 589 patients with cardiac arrest, 25 618 (43%) diedduringattemptedresuscitation.Of the33 971patientswho had successful ROSC, 26 327 (77.5%)were available for analysis.For thisgroup, theoverall likelihoodofdischargealivewithout severe neurological disability was only 24%. Do-notresuscitate orders were placed within 12 hours for 22.6% of patients, and an additional 14.5% of patients had DNR orders placed up to day 5 after cardiac arrest. In the best prognostic decile (n = 2396), DNRorderswere placed in the first 12 hours for 169 (7.1%)patients, and 1550 (64.7%)weredischargedwith favorable neurologic outcome. In contrast, of the 2667 patients in theworst prognostic decile, 108 (4%) had a favorable outcome, yet only 959patients (36%) hadDNRorders placed. This pattern was similar for DNR orders placed up to 5 days. Not surprisingly, patients in the best prognostic decile were younger, had less preexisting comorbidity, andhad less acute severity of illness, such as a lower chance of requiring mechanical ventilation, than patients in the worst-risk decile. Within the best decile, patients who had DNR orders placed wereolder andhadmoresevere illness than thosewhodidnot. Within theworst prognostic decile, however, the clinical characteristics were quite similar between patients who did and did not have DNR orders placed. It is likely that this study reflects currentUSpractice, even though thehospitals representonly 10%ofallUShospitals and participatevoluntarily. Inaddition,amoderatenumberofcases were excluded from analysis because of missing data, although the authors demonstrated that thebaseline characteristics of these patients were similar to those included in the analysis. Using the CASPRI scorewas a sound approach to assess the extent towhichdecisions to instituteDNRorders varied based on patient characteristics, although it is important to note that this score is not used currently by clinicians. Do-not-resuscitate orders are not analogous towithdrawal or withholding of life support. It is possible that, absent DNRorders, care was nonetheless limited in other ways for patients with poor prognosis. However, hospital costs, length of stay, and resourceuseamongpatientswithpoorprognosisyetwithout DNR orders were high, suggesting anywithholding of life support occurred late in the course of care. These results could be framed as a glass half-full or halfempty. On the one hand, it is reassuring that DNR orders, if placed, are generally done quickly and appear to be instituted infrequently for patients likely to fare well and commonly for those likely to fare poorly. However, two-thirds of patientswith anextremelypoor chanceof good recoverywere managedwithout institutionofDNRorders and incurredhigh costs of care. Given that cardiac arrest occurs in a broad range of patients, and that there are only a fewcasesperhospital per year,most clinical teamswill only occasionally care for a survivor of in-hospital cardiac arrest. It is therefore quite possible that the primary teammay be neither good at nor comfortablewithestimatingprognosis. Inmany instances, cardiac arrest substantially changes prognosis, with potentially important implications for aggressiveness of care. Both the clinical team and family members need to absorb the information. It is perhaps surprising that most DNR orders were instituted so soon after cardiac arrest. As can occur when relying on registry data, the study by Fendler et al has some important missing information, especially on the large portion of patients with very poor prognosis for whom DNR orders were not instituted. What were the opinions of the clinical team and familymembers in these instances? What were the patient’s preferences? What efforts were undertaken to establish a prognosis and ensure converRelated article page 1264 Opinion

ContextAnalysis of predictors of cardiac events in hereditary long-QT syndrome (LQTS) has primarily considered syncope as the predominant end point. Risk factors specific for aborted cardiac arrest and sudden cardiac death have not been investigated.ObjectiveTo identify risk factors associated with aborted cardiac arrest and sudden cardiac death during adolescence in patients with clinically suspected LQTS.Design, Setting, and ParticipantsThe study involved 2772 participants from the International Long QT Syndrome Registry who were alive at age 10 years and were followed up during adolescence until age 20 years. The registry enrollment began in 1979 at 5 cardiology centers in the United States and Europe.Main Outcome MeasuresAborted cardiac arrest or LQTS-related sudden cardiac death; follow-up ended on February 15, 2005.ResultsThere were 81 patients who experienced aborted cardiac arrest and 45 who had sudden cardiac death; 9 of the 81 patients who had an aborted cardiac arrest event experienced subsequent sudden cardiac death. Significant independent predictors of aborted cardiac arrest or sudden cardiac death during adolescence included recent syncope, QTc interval, and sex. Compared with those with no syncopal events in the last 10 years, patients with 1 or 2 or more episodes of syncope 2 to 10 years ago (but none in the last 2 years) had an adjusted hazard ratio (HR) of 2.7; (95% confidence interval [CI], 1.3-5.7; P

Context High-quality cardiopulmonary resuscitation (CPR) may improve both cardiac and brain resuscitation following cardiac arrest. Compared with manual chest compression, an automated load-distributing band (LDB) chest compression device produces greater blood flow to vital organs and may improve resuscitation outcomes. Objective To compare resuscitation outcomes following out-of-hospital cardiac arrest when an automated LDB-CPR device was added to standard emergency medical services (EMS) care with manual CPR. Design, setting, and patients Multicenter, randomized trial of patients experiencing out-of-hospital cardiac arrest in the United States and Canada. The a priori primary population was patients with cardiac arrest that was presumed to be of cardiac origin and that had occurred prior to the arrival of EMS personnel. Initial study enrollment varied by site, ranging from late July to mid November 2004; all sites halted study enrollment on March 31, 2005. Intervention Standard EMS care for cardiac arrest with an LDB-CPR device (n = 554) or manual CPR (n = 517). Main outcome measures The primary end point was survival to 4 hours after the 911 call. Secondary end points were survival to hospital discharge and neurological status among survivors. Results Following the first planned interim monitoring conducted by an independent data and safety monitoring board, study enrollment was terminated. No difference existed in the primary end point of survival to 4 hours between the manual CPR group and the LDB-CPR group overall (N = 1071; 29.5% vs 28.5%; P = .74) or among the primary study population (n = 767; 24.7% vs 26.4%, respectively; P = .62). However, among the primary population, survival to hospital discharge was 9.9% in the manual CPR group and 5.8% in the LDB-CPR group (P = .06, adjusted for covariates and clustering). A cerebral performance category of 1 or 2 at hospital discharge was recorded in 7.5% of patients in the manual CPR group and in 3.1% of the LDB-CPR group (P = .006). Conclusions Use of an automated LDB-CPR device as implemented in this study was associated with worse neurological outcomes and a trend toward worse survival than manual CPR. Device design or implementation strategies require further evaluation. Trial registration clinicaltrials.gov Identifier: NCT00120965.