Uchenna R Ofoma (Geisinger Health System, Danville, USA) and others report in the Journal of the American College of Cardiology that patients who have a cardiac arrest during nights or weekends continue to experience lower survival compared to patients who arrest during daytime hours. They state that survival to discharge in patients who arrested during “off-hours” was an absolute 3.8% lower compared to patients who arrested during “on-hours”.
A previous study found rates of survival and neurological outcomes were 15% to 20% lower among patients who arrested during nights or weekends (off-hours). Ofoma et al for this present study sought to determine how survival differences have changed over time in patients who arrest during on-hours vs. off-hours. On-hours was categorised as 7am to 10.59pm Monday to Friday. Off-hours was described as 11pm to 6:59am Monday to Friday or anytime on weekends.
They identified 151,071 patients at least 18 years old who experienced in-hospital cardiac arrest between January 2000 and December 2014 using the GWTG-Resuscitation registry. More than half of the included patients experienced cardiac arrest during off-hours; overall, 62.4% of patients survived acute resuscitation efforts and 18.6% survived to hospital discharge. Both on- and off-hours groups had a similar prevalence of comorbidities, location of arrest and interventions in place at time of arrest.
Overall, survival to discharge increased in both groups over the 15-year study period: for on-hours, from 16% in 2000 to 25.2% in 2014; and for off-hours, 11.9% in 2000 to 21.9%in 2014. However, the survival during off-hours remained significantly lower compared to on-hours. Ofoma comments: “While it was encouraging to see that survival has increased in both groups of patients, the persistent survival disparities between on-hours and off-hours remains disheartening. Timing of in-hospital cardiac arrest has a major impact on a patient’s outcome, so we must make this an area to focus quality improvement efforts to ensure that improved survival trends are sustained over time.”
According to Ofoma et al, poor survival during off-hours is likely due to several factors:
- Changes to hospital staffing patterns during nights and weekends
- Physicians workings nights and weekends provide coverage to patients they may be less familiar with
- Nurse-to-patient ratios are lower during off-hours
- The impact of shift work, particularly during night time, has been shown to impact psychomotor skills and performance of skilled activities, such as cardiopulmonary resuscitation.
“Nearly 50% of in-hospital cardiac arrests take place during ‘off-hours.’ By determining how survival has changed in recent years, we may be able to identify opportunities for quality improvement efforts. If we can improve survival for cardiac arrests that occur during off-hours, it could impact a substantial number of patients,” Ofoma notes.