Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital.
OBJECTIVE
To determine the incidence of avoidable cardiac arrest among patients who had received resuscitation in a district general hospital. To establish how location and individual or system factors influence avoidable cardiac arrest in order to develop an evidence-based preventive strategy.


METHODS
Expert panel review of case-notes from 139 consecutive adult in-hospital cardiac arrests over 1 year.


RESULTS
There were 32,348 adult admissions in 1999 with 1,023 deaths. The cardiac arrest team was activated 139 times: 118 were for primary in-hospital cardiac arrest. The cardiac arrest rate excluding 'do not attempt resuscitation' (DNAR) cases was 3.8/1000 admissions. In 88.5% of deaths there was a DNAR policy. Survival to hospital discharge following resuscitation was 14%. Among the 118 cases, the panel unanimously agreed that 61.9% of arrests were potentially avoidable, rising to 68% when emergency department arrests were excluded (66 and 73% for majority opinion). Cardiac arrests were more likely at the weekend than during the week (P = 0.02). The odds of potentially avoidable cardiac arrest was 5.1 times greater for patients in general wards than critical care areas (P < 0.001); patients in critical care areas were more likely to survive (P < 0.001). The odds of potentially avoidable cardiac arrest was 12.6 times greater for patients nursed in a clinical area judged 'inappropriate' for their main complaint (P < 0.002, Fisher's exact test) compared to those nursed in 'appropriate' areas. The panel agreed that 100% of potentially avoidable arrests were judged to have received inadequate prior treatment. Clinical signs of deterioration in the preceding 24 h were not acted upon in 48%, and review was confined to a house officer in 45%.


CONCLUSIONS
The majority of treated in-hospital cardiac arrests are potentially avoidable. Multiple system failures include delays and errors in diagnosis, inadequate interpretation of investigations, incomplete treatment, inexperienced doctors and management in inappropriate clinical areas.
Hodgetts
Timothy J
TJ
Royal Centre for Defence Medicine, Selly Oak Hospital, Birmingham B29 6 JD, UK.
Kenward
Gary
G
Vlackonikolis
Ioannis
I
Payne
Susan
S
Castle
Nicolas
N
Crouch
Robert
R
Ineson
Neil
N
Shaikh
Loua
L
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019317:Evidence-Based Medicine; D005260:Female; D006323:Heart Arrest / Q000453:epidemiology* / Q000401:mortality; D006760:Hospitalization; D006767:Hospitals, District; D006769:Hospitals, General; D006801:Humans; D008297:Male; D019300:Medical Errors; D008875:Middle Aged; D012151:Resuscitation / Q000401:mortality; D006113:United Kingdom