| 1. |
- Jonsson, Hanna, et al.
(författare)
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Is frailty associated with long-term survival, neurological function and patient-reported outcomes after in-hospital cardiac arrest? : - A Swedish cohort study
- 2022
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Ingår i: Resuscitation. - : Elsevier. - 0300-9572 .- 1873-1570. ; 179, s. 233-242
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Tidskriftsartikel (refereegranskat)abstract
- Background: Frailty is associated with poor 30-days survival after in-hospital cardiac arrests (IHCA). The aim was to assess how pre-arrest frailty was associated with long-term survival, neurological function and patient-reported outcomes in elderly survivors after IHCA.Methods: Patients aged >= 65 years with IHCA at Karolinska University Hospital between 2013-2021 were studied. Frailty was assessed by the Clinical Frailty Scale (CFS) based on clinical records and categorised into non-frail (1-4) or frail (5-7). Survival was assessed in days. Neurological function was assessed by the Cerebral Performance Category scale (CPC). A telephone interview was performed six months post-IHCA and included the questionnaires EuroQoL-5 Dimensions-5 Levels and Hospital Anxiety and Depression Scale.Results: Totally, 232 (28%) out of 817 eligible patients survived to 30-days. Out of 232, 65 (28%) were frail. Long-term survival was better for non-frail than frail patients (6 months (92% versus 75%, p-value < 0.01), 3 years (74% vs 22%, p-value < 0.01)). The vast majority of both non-frail and frail patients had unchanged CPC from admittance to discharge from hospital (87% and 85%, respectively, p-value 0.52). The 121 non-frail patients reported better health compared to 27 frail patients (EQ-VAS median 70 versus 50 points, p-value < 0.01) and less symptoms of depression than frail (16% and 52%, respectively, p-value < 0.01).Conclusion: Frail patients suffering IHCA survived with the same neurological function they had at admittance. Although one in five frail patients survived to three years, frailty was associated with a marked decrease in long-term survival as well as increased symptoms of depression and poorer general health.
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| 2. |
- Piscator, Eva
(författare)
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Do-Not-Attempt-Cardiopulmonary-Resuscitation decisions in the hospital setting
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: A Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) order can be placed when CPR is not in accordance with the patient’s will, when CPR is considered not to benefit the patient, or when CPR is very unlikely to be successful because the patient is dying from an irreversible condition. The decision to withhold CPR involves assessment of the predictors for favourable outcome, in compound with the patient’s values and goals of care to make a decision that is of benefit to the patient. Throughout this process there are ethical directives and legislations to relate to. Previous studies have shown that it is difficult for medical personnel to accurately predict outcome after cardiac arrest, but there is no supportive prediction model established in clinical practice. There are indications of shortages in adherence to legislation regarding DNACPR orders in our setting, but clinical practice has not been evaluated on a larger scale. Further, there is scarce knowledge about the grounds for DNACPR decisions based on the clinical practice, about the use of DNACPR orders, and the characteristics of those receiving them. Aims: The overall aim of this thesis was to facilitate and investigate the decision process for DNACPR order placement in the hospital setting and fill knowledge gaps in the epidemiology of DNACPR orders. More specifically, the aim was external validation of the pre-arrest prediction model the Good Outcome Following Attempted Resuscitation (GOFAR) score (study I), model update of the GO-FAR score with development of a prediction model for the Swedish setting (study II), evaluation of adherence to the Swedish legislation regarding documentation of DNACPR order placement, exploration of the decision process in clinical practice (study III), and assessment of the use of DNACPR orders, characteristics and outcome for the patients (study IV). Methods: Study I and II included adult in-hospital cardiac arrests (IHCA) in the Swedish Registry for Cardiopulmonary Resuscitation (SRCR) from 2013 to 2104 in the Stockholm region. Outcome in study I was neurologically intact survival defined as Cerebral Performance Category score (CPC) 1 and in study II outcome was favourable neurological survival defined as CPC 1–2. Outcome and patient characteristics were retrieved from SRCR, predictor variables from manual review of electronic patient records and from the National patient registry (NPR). External validation of the GO-FAR score was based on assessment of the discrimination with area under the receiver operating characteristics (AUROC) curve, calibration and risk group categorisation. Model update was based on the results in study I and included change of outcome and addition of the predictor chronic comorbidity. The study population and variables in III and IV was obtained from Karolinska University Hospital’s local administrative database and NPR and included adult admissions through the Emergency Department (ED) from 1 January to 31 October 2015. Study III included only patients with DNACPR orders issued during hospitalisation. In study III the DNACPR form in the electronic patient record was used to evaluate adherence to legislation regarding documentation of DNACPR orders and to explore aspects of the decision process in clinical practice through qualitative content analysis. Results: Study I and II included 717 IHCA. In study I the GO-FAR score showed good discrimination with AUROC of 0.82 (95% CI 0.78–0.86), but risk group categorisation and calibration showed an underestimation of the probability of neurologically intact survival. Study II provided the updated prediction model the Prediction of outcome for In-Hospital Cardiac Arrest (PIHCA) score. The AUROC for the PIHCA score was 0.81 (95% CI 0.807– 0.810). With a cut-off of 3% likelihood of favourable neurological survival the PIHCA score could classify patients with favourable neurological outcome correctly (99% sensitivity), but for patients with poor outcome (death or CPC >2) the PIHCA score’s correct classification was limited (8% specificity). This was outweighed by a high negative predictive value (97%) for classification into low likelihood of favourable neurological survival (≤ 3%). Study III included 3,583 DNACPR forms. Mainly due to impaired cognition, it was not possible to consult with the patient 40% of cases. For these patients, a relative was consulted in 46%. For competent patients, consultation took place in 28% and the most common patient attitude was that the DNACPR order adhered with their preferences. Severe chronic comorbidity, malignancy or multimorbidity alone or in combination with acute illness was most common as grounds for DNACPR orders. All requirements in the legislation regarding documentation of DNACPR orders were fulfilled in 10%. Study IV included 25,646 adult admissions to Karolinska University Hospital of whom 11% received a DNACPR order during the hospitalisation. Patients with DNACPR orders were older, with higher burden of chronic comorbidities and more severe acute illness, hospital mortality and one-year mortality compared to those without. Characteristics of patients with DNACPR orders were similar regardless of hospital mortality, however, patients who died in-hospital presented more acutely unwell in the ED. Change in CPR status during hospitalisation was 5% and upon subsequent admission 14%. For patients discharged with DNACPR orders, reversal of DNACPR status upon subsequent admission was 32%, with uncertainty as to whether this reversal was active or a consequence of a lack of consideration. Conclusions: The GO-FAR score should only with caution be taken into clinical practice in our setting without update. The updated PIHCA score has a potential to be used in our setting, but external validation and further exploration of clinical use is warranted before implementation. There are shortcomings in the decision process regarding documentation of DNACPR orders and further research is warranted to establish the most effective interventions to strengthen clinical practice. For most patients DNACPR order placement was in line with their preferences, but for a substantial proportion of patients impaired cognition made shared decision impossible. The perspective of risk for cessation of circulation for patients with severe comorbidity can lay in the present situation, but also with the perspective of the near future. One out of ten adult patients received a DNACPR order after emergency admission to a Swedish University hospital. Upon subsequent admissions, for patients with a DNACPR order on previous hospitalisation, reversal of DNACPR status occurred for onethird. This should merit attention as it was uncertain if this reversal was active or represented a lack of consideration.
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| 3. |
- Piscator, Eva, et al.
(författare)
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Low adherence to legislation regarding Do-Not-Attempt-Cardiopulmonary-Resuscitation orders in a Swedish University Hospital
- 2021
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Ingår i: Resuscitation Plus. - : Elsevier BV. - 2666-5204. ; 6
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Tidskriftsartikel (refereegranskat)abstract
- Background The ethical principles of resuscitation have been incorporated into Swedish legislation so that a decision to not attempt cardiopulmonary resuscitation (DNACPR) entails (1) consultation with patient or relatives if consultation with patient was not possible and documentation of their attitudes; (2) consultation with other licensed caregivers; (3) documentation of the grounds for the DNACPR. Our aim was to evaluate adherence to this legislation, explore the grounds for the decision and the attitudes of patients and relatives towards DNACPR orders. Methods We included DNACPR forms issued after admission through the emergency department at Karolinska University Hospital between 1st January and 31st October, 2015. Quantitative analysis evaluated adherence to legislation and qualitative analysis of a random sample of 20% evaluated the grounds for the decision and the attitudes. Results The cohort consisted of 3583 DNACPR forms. In 40% of these it was impossible to consult the patient, and relatives were consulted in 46% of these cases. For competent patients, consultation occurred in 28% and the most common attitude was to wish to refrain from resuscitation. Relatives were consulted in 26% and they mainly agreed with the decision. Grounds for the DNAR decision was most commonly severe chronic comorbidity, malignancy or multimorbidity with or without an acute condition. All requirements of the legislation were fulfilled in 10% of the cases. Conclusion In 90% of the cases physicians failed to fulfil all requirements in the Swedish legislation regarding DNAR orders. The decision was mostly based on chronic, severe comorbidity or multimorbidity.
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| 4. |
- Piscator, Eva, et al.
(författare)
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Prearrest prediction of favourable neurological survival following in-hospital cardiac arrest : The Prediction of outcome for In-Hospital Cardiac Arrest (PIHCA) score.
- 2019
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Ingår i: Resuscitation. - : Elsevier BV. - 0300-9572 .- 1873-1570. ; 143, s. 92-99
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: A prearrest prediction tool can aid clinicians in consolidating objective findings with clinical judgement and in balance with the values of the patient be a part of the decision process for do-not-attempt-resuscitation (DNAR) orders. A previous prearrest prediction tool for in-hospital cardiac arrest (IHCA) have not performed satisfactory in external validation in a Swedish cohort. Therefore our aim was to develop a prediction model for the Swedish setting.METHODS: Model development was based on previous external validation of The Good Outcome Following Attempted Resuscitation (GO-FAR) score, with 717 adult IHCAs. It included redefinition and reduction of predictors, and addition of chronic comorbidity, to create a full model of 9 predictors. Outcome was favourable neurological survival defined as Cerebral Performance Category score 1-2 at discharge. The likelihood of favourable neurological survival was categorised into very low (<1%), low (1-3%) and above low (>3%).RESULTS: We called the model the Prediction of outcome for In-Hospital Cardiac Arrest (PIHCA) score. The AUROC was 0.808 (95% CI 0.807-0.810) and calibration was satisfactory. With a cutoff of 3% likelihood of favourable neurological survival sensitivity was 99.4% and specificity 8.4%. Although specificity was limited, predictive value for classification into ≤3% likelihood of favorable neurological survival was high (97.4%) and false classification into ≤3% likelihood of favourable neurological survival was low (0.6%).CONCLUSION: The PIHCA score has the potential to be used as an objective tool in prearrest prediction of outcome after IHCA, as part of the decision process for a DNAR order.
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| 5. |
- Piscator, Eva, et al.
(författare)
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Predicting neurologically intact survival after in-hospital cardiac arrest-external validation of the Good Outcome Following Attempted Resuscitation score.
- 2018
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Ingår i: Resuscitation. - : Elsevier BV. - 0300-9572 .- 1873-1570. ; 128, s. 63-69
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: A do-not-attempt-resuscitation order is issued when it is against the wishes of the patient that cardiopulmonary resuscitation is performed, or when the chance of good quality survival is minimal. Therefore it is essential for physicians to make an objective prearrest prediction of the outcome after an in-hospital cardiac arrest (IHCA). Our aim was external validation of the Good Outcome Following Attempted Resuscitation (GO-FAR) score in a population based setting.METHODS: The study was based on a retrospective cohort of adult IHCAs in Stockholm County 2013-2014 identified through the Swedish Cardiopulmonary Resuscitation Registry. This registry provided patient and event characteristics and neurological outcome at discharge. Neurologically intact survival is defined as Cerebral Performance Category score (CPC) 1 at discharge. Data for the GO-FAR variables was obtained from manual review of electronic patient records. Model performance was evaluated by measure of discrimination with the area under the receiver operating curve (AUROC) and calibration with assessment of the calibration plot.RESULTS: The cohort included 717 patients with neurologically intact survival at discharge of 22%. In complete case analysis (523 cases) AUROC was 0.82 (95% CI 0.78-0.86) indicating good discrimination. The calibration plot showed that the GO-FAR score systematically underestimates the probability of neurologically intact survival.CONCLUSION: The GO-FAR score has satisfactory discrimination, but assessment of the calibration shows that neurologically intact survival is systematically underestimated. Therefore, only with caution should it without model update be taken into clinical practice in settings similar to ours.
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| 6. |
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| 7. |
- Piscator, Eva, et al.
(författare)
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Survival after in-hospital cardiac arrest is highly associated with the Age-combined Charlson Co-morbidity Index in a cohort study from a two-site Swedish University hospital
- 2015
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Ingår i: Resuscitation. - : Elsevier Ireland Ltd. - 0300-9572 .- 1873-1570. ; 99, s. 79-83
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Tidskriftsartikel (refereegranskat)abstract
- Abstract Background In-hospital cardiac arrest (IHCA) has a poor prognosis and clinicians often write “Do-Not-Attempt-Resuscitation” (DNAR) orders based on co-morbidities. Aim To assess the impact of the Age-combined Charlson Co-morbidity Index (ACCI) on 30-days survival after IHCA. Material and methods All patients suffering IHCA at Karolinska University Hospital between 1st January and 31st December 2014 were included. Data regarding patient characteristics, co-morbidities and survival were drawn from the electronic patient records. Co-morbidities were assessed prior to the IHCA as ICD-10 codes according to the ACCI. Differences in survival were assessed with adjusted logistic regression models and presented as Odds Ratios with 95% Confidence Intervals (OR, 95% CI) between patients with an ACCI of 0–4 points versus those with 5–7 points, as well as those with ≥8 points. Adjustments included hospital site, heart rhythm, ECG surveillance, witnessed status and place of IHCA. Results In all, 174 patients suffered IHCA, of whom 41 (24%) survived at least 30 days. Patients with an ACCI of 5–7 points had a minor chance and those with an ACCI of ≥8 points had a minimal chance of surviving IHCA compared to those with an ACCI of 0–4 points (adjusted OR 0.10, 95% CI 0.04–0.26 and OR 0.04, 95% CI 0.03–0.42, respectively). Conclusion Patients with a moderate or severe burden of ACCI have a minor chance of surviving an IHCA. This information could be used as part of the decision tools during ongoing CPR, and could be an aid for clinicians in planning care and discussing DNAR orders.
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