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PubMedDate not supplied

The locations of nonresidential out-of-hospital cardiac arrests in the City of Pittsburgh over a three-year period: implications for automated external defibrillator placement.

OBJECTIVES: To determine the locations of nonresidential out-of-hospital cardiac arrests (OHCAs) in the City of Pittsburgh and to determine whether there are "high-risk" locations that might benefit from placement of automated external defibrillators (AEDs). METHODS: This was a retrospective case review of paramedic calls for OHCA over a three-year period, in a mid-sized northeastern city. Cardiac arrests that were traumatic or for which the patients were dead on arrival (DOA) or had advanced directives for no resuscitation were excluded. Cardiac arrests that occurred in a public location (i.e., not a private residence) were categorized. RESULTS: A total of 971 OHCAs occurred in the City of Pittsburgh from January 1, 1997, to December 31, 1999. Of these, 575 (59%) occurred in private residences, and 396 (41%) occurred in nonresidential locations. Fifteen locations had at least one cardiac arrest per year for three years, accounting for 166 (43%) of the total nonresidential OHCAs. Twelve locations had two arrests during the three-year period, accounting for 24 (6%) of the total nonresidential OHCAs. One hundred ninety-four locations had a single episode of cardiac arrest, accounting for 51% of the OHCAs. Nursing homes and dialysis centers accounted for 178 (94%) OHCAs in the 27 locations that had two or more cardiac arrests. A local sports/events complex (Three Rivers Stadium) was the only other single location to have more than two cardiac arrests in the three-year study period, with a total of three. However, events at this complex are routinely staffed by paramedics equipped with defibrillators. CONCLUSION: The majority of nonresidential OHCAs occur as singular, isolated events. Other than nursing homes and dialysis centers, there were no identifiable high-risk locations for nonresidential OHCA within the City of Pittsburgh.

Ambulatory Care Facilities↗
PubMed2005

Termination of resuscitative efforts for out-of-hospital cardiac arrests.

OBJECTIVE: To determine the rate of termination of resuscitative efforts for out-of-hospital cardiac arrest patients and whether variability exists among different base hospitals providing online medical control (OLMC). METHODS: This was an observational one-year study that included all adult patients in the city of Los Angeles with nontraumatic, out-of-hospital cardiac arrests with attempted resuscitative efforts by paramedics. OLMC was provided by 13 base hospitals. The main outcome measure was the incidence of termination of resuscitative efforts on scene as directed by OLMC. RESULTS: Of 1,700 patients, 151 (9%) had resuscitative efforts terminated on scene via direction by OLMC. Patients pronounced on scene were statistically more likely to be older, be found in an extended care facility, have an unwitnessed arrest, and present in asystole. Two base hospitals were more likely to terminate resuscitative efforts via OLMC than all others. Incidence at base hospital A was 37% (odds ratio, 18.6; 95% confidence interval = 11.7 to 30.0; p < 0.0001); incidence at base hospital B was 14% (odds ratio, 3.3; 95% confidence interval = 1.9 to 5.5; p < 0.0001), and incidence at all other base hospitals was 5%. Cardiac arrest patients handled by base hospital A were more likely to be found in ventricular fibrillation; those patients handled by base hospital B had shorter emergency medical services response times and were more likely to be found in an extended care facility. All other characteristics of cardiac arrest patients were not significantly different among the base hospitals. CONCLUSIONS: There is significant variability in Los Angeles, depending on the particular base hospital that provides OLMC, in pronouncement of death and termination of resuscitative efforts for medical cardiac arrest in the field. Given potential ethical, logistical, and economic concerns, efforts to assure consistency in the practice of discontinuing resuscitative efforts in the field is warranted.

Adult↗
PubMed2005

Somatosensory and brainstem auditory evoked potentials in cardiac arrest patients treated with hypothermia.

OBJECTIVE: To evaluate the prognostic value of short-latency median nerve somatosensory evoked potentials and brainstem auditory evoked potentials in outcome prediction for comatose cardiac arrest patients treated with hypothermia. DESIGN: Prospective, randomized, controlled trial of mild hypothermia after out-of-hospital cardiac arrest; a substudy of the European Hypothermia After Cardiac Arrest study. SETTING: Intensive care unit of a tertiary referral hospital (Helsinki University Central Hospital). PATIENTS: Sixty consecutive patients (aged 18-75 yrs) resuscitated from out-of-hospital ventricular fibrillation and comatose at 24 hrs after cardiac arrest; all patients were randomly assigned either to therapeutic hypothermia of 33 degrees C or normothermia. INTERVENTIONS: All patients received standard intensive care for at least 2 days. Patients randomized to hypothermia were cooled with an external cooling device for 24 hrs and then allowed to rewarm slowly for 12 hrs. In the normothermia group, the core temperature was kept below 38 degrees C with antipyretics and by physical means. The clinical outcome was assessed 6 months after cardiac arrest. MEASUREMENTS AND MAIN RESULTS: Somatosensory evoked potentials and brainstem auditory evoked potentials were recorded 24-28 hrs after cardiac arrest. All wave latencies were significantly prolonged in the hypothermia group. Bilaterally absent N20 waves predicted permanent coma with a specificity of 100% in both treatment groups. Brainstem auditory evoked potential recordings did not correlate with the outcome in either treatment group. CONCLUSIONS: The prognostic ability of median nerve short-latency somatosensory evoked potentials does not seem to be affected by therapeutic hypothermia. Brainstem auditory evoked potentials had no additional value in outcome prediction.

Adult↗
PubMed1986

[Cardiac arrest during anesthesia and the recovery period. Data from the INSERM survey 1978-1982].

This report analyses rate, predisposing factors, causes and outcome of 458 cardiac arrests occurring during anaesthesia and the following 24 hours and collected in France by a national prospective survey between 1978 and 1982. The overall rate of cardiac arrests was 1 per 433 anaesthetics, resulting in death before the 24th postoperative hour in 79% of cases, i.e. 1 per 547 anaesthetics. Cardiac arrests not related to anaesthesia were three times more frequent than those related to anaesthesia. Among these, one half is partially related to anaesthesia and the other totally. The prognosis of cardiac arrests totally related to anaesthesia is six times better than that of not related arrests (64% of recoveries without sequelae vs 10%). The cardiac arrests not related to anaesthesia occur mainly at the end of surgery and the following 24 hours. The main causes are hypovolaemia, sepsis and severity of surgical illness. Among cardiac arrests related to anaesthesia, a quarter occurred during induction, another during maintenance and a half during recovery from anaesthesia. The first were mainly related to histamine release and had the lowest mortality rate. The last were mainly related to unrecognized postoperative respiratory depression and resulted in the highest mortality. The authors underline the necessity of better preoperative detection of high risk patients, smooth induction of anaesthesia, continuous clinical monitoring of the patient during surgery and the recovery period.

Age Factors↗
PubMed2005

[Cardiac arrest in a 17-year-old boy--a case report].

Cardiac arrest (CA) refers to abrupt cessation of cardiac pump function. Most sudden deaths in young people are of cardiac origin, at the same time most patients have unrecognised prior heart disease. We report a case of a 17-year-old boy with cardiac arrest induced by ventricular fibrillation. Sinus rhythm was restored after one hour's resuscitation. Based upon elevated necrotic markers, ECG changes and echocardiographic examinations the diagnosis of anterolateral myocardial infarction was established. Coronary angiography revealed only a small myocardial bridge. The patient in a poor general and unconscious state was transferred to the Coronary Care Unit of the Department of Coronary Disease. The patient improved after treatment and without neurological deficit or circulatory insufficiency continued cardiac rehabilitation in a spa hospital. The paper reviews differential diagnosis of cardiac arrest, treatment modalities and describes the course of hospitalisation.

Adolescent↗
PubMed1997

Cerebrospinal fluid creatine kinase BB isoenzyme activity and neurologic prognosis after cardiac arrest.

OBJECTIVE: To assess the relationship between CSF creatine kinase BB isoenzyme activity (CSF CKBB) and neurologic outcome after cardiac arrest in clinical practice. BACKGROUND: CSF CKBB reflects the extent of brain damage following cardiac arrest. METHODS: To help with prognosis, treating physicians ordered CSF CKBB tests on 474 patients over 7.5 years; 351 of these patients had experienced a cardiac arrest. Assays were performed in one laboratory using agarose electrophoresis. By chart review, we determined awakening status for all patients, defined as the patient having comprehensible speech or following commands. RESULTS: CSF CKBB was usually sampled 48 to 72 hours after cardiac arrest and was strongly associated with awakening (p < < 0.001). The median was 4 U/l for 61 patients who awakened and 191 U/l for 290 who never awakened. For those who awakened, 75% of CKBB levels were < 24 U/l, and for those who never awakened, 75% were > 86 U/l. The highest value in a patient who awakened was 204 U/l, a cutoff that yielded a specificity of 100% of never awakening but a sensitivity of forty-eight percent. Only nine patients who awakened had CSF CKBB values greater than 50 U/l, and none regained independence in activities of daily living. Only three unconscious patients were still alive at last contact, with follow-up of 63, 107, and 109 months. Using logistic regression, the probability of never awakening given a CSF CKBB result can be estimated as: 1/(1 + L), where L = e raised to (0.1267 - 0.0211 x CSF CKBB [U/l]). CONCLUSION: CSF CKBB measurement helps to estimate degree of brain damage and thus neurologic prognosis after cardiac arrest. However, results of this retrospective study could reflect in part a self-fulfilling prophecy.

Aged↗
PubMed1993

What are representative survival rates for out-of-hospital cardiac arrest? Insights from the New Haven (Conn) experience.

BACKGROUND: Survival rates from out-of-hospital cardiac arrests due to ventricular fibrillation or pulseless ventricular tachycardia vary greatly. The majority of published reports indicate a survival range from 11% to 33%, depending on the area of observation. Two recent series from major metropolitan centers describe markedly less favorable outcomes and have led to speculation that dense urbanization may contribute to worse outcomes. METHODS: Examination of a consecutive series of out-of-hospital cardiac arrests in New Haven, Conn, a city of 127,000 people and 55 km2 with a two-tiered emergency response system. All cases of nontraumatic cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia occurring outside of a hospital between January 1988 and June 1989 were considered. That city's emergency medical system employs emergency medical technicians and paramedics. Standard resuscitation techniques were employed; high-dose epinephrine and interposed abdominal counterpulsations were not routine interventions. The main outcome measure was survival to hospital discharge. RESULTS: Three (4.0%) of 75 patients survived cardiac arrest and were discharged alive from the hospital. Two (5.3%) of 38 witnessed arrests resulted in hospital discharges. Patient demographics were typical of those reported from other cities that have published outcomes data. Few patients (16%) received bystander-initiated cardiopulmonary resuscitation. CONCLUSION: There is increasing evidence that previously recognized standards for resuscitation success may not be present in certain types of municipalities, including this northeastern city. A registry of outcomes from out-of-hospital cardiac arrests would help to clarify the true national experience.

Connecticut↗
PubMed2006

Time to give the first medication during resuscitation in out-of-hospital cardiac arrest.

OBJECTIVE: There is no evidence showing an impact from any advanced cardiac life support (ACLS) medications on patient survival following cardiac arrest. One potential reason for a lack of such benefit may be medication timing. We formed the hypothesis that medications are given late after rescuer arrival, limiting any benefit. We performed a meta-analysis to determine the time from emergency medical services (EMS) dispatch to first medication administration, regardless of route, during out-of-hospital cardiac arrest (OOHCA). Then, the mean time and ranges of reported study medication delivery in clinical trials where medication was the experimental intervention was determined. METHODS: We conducted a comprehensive literature review between January 1990 and August 2005 in MEDLINE using the following MeSH headings: cardiopulmonary resuscitation, cardiac arrest, heart arrest, EMS, EMT, ambulance, and the names of all ACLS medications. We reviewed the abstracts of 632 studies and full manuscripts of 248 published papers. We eliminated the following articles from further analysis: non-peer reviewed; all without human primary data (includes review articles, guidelines or consensus manuscripts, editorials, or simulation studies); animal data; case reports. We used no language restriction. From this search, our independent reviewers found 17 papers that contained information on time to medication administration. RESULTS: We analyzed reporting of drug delivery time to 7617 patients in 32 different emergency medical services systems. Time to first medication delivery by any route was a mean of 17.7 min (range 10.0-25.0; 95% CI around mean 10.6, 24.8). Time to intravenous experimental medication administration was a mean of 19.4 min (range 13.3-25.0; 95% CI around mean 12.8, 25.9). CONCLUSIONS: Medications are given late during out-of-hospital cardiac arrest, even in cohorts where drug delivery is a key study intervention.

Algorithms↗
PubMed2002

Surgical coronary revascularization and antiarrhythmic therapy in survivors of out-of-hospital cardiac arrest.

BACKGROUND: Patients who survive out-of-hospital cardiac arrest are at high risk for recurrent arrest. Coronary artery bypass grafting (CABG) confers a survival advantage, but it is unclear whether antiarrhythmic drugs or an implanted defibrillator confer added benefit. This study was designed to determine predictors for further treatment, survival, and therapeutic internal cardiac defibrillator (ICD) discharge in this patient population. METHODS: One hundred and eight patients undergoing CABG after out-of-hospital cardiac arrest were identified over a 12-year period. Case records were retrospectively reviewed. Follow-up was obtained and predictors of outcome events were analyzed. RESULTS: Fifty-four (50%) patients underwent CABG only. Fifty-four received additional treatment that included ICD placement in 23 (21%), antiarrhythmic medications in 19 (18%), or both in 12 (11%). Predictors of ICD placement included left ventricular ejection fraction (LVEF) less than 40% and perioperative intraaortic balloon counterpulsation. ICD or medical management increased survival in patients with LVEF <40%. Predictors of increased mortality included age >65 years, Cleveland Severity Score >8, and female gender. Predictors of therapeutic ICD discharge included age >65 years, reoperative CABG, LVEF <40%, and positive postoperative electrophysiological (EP) study. No patient with a negative postoperative EP study received an ICD, and none suffered sudden cardiac death during follow-up. CONCLUSIONS: Patients with coronary artery disease anatomically suitable for CABG who survive an acute out-of-hospital cardiac arrest should undergo EP testing after CABG. Approximately half of these patients are adequately treated by CABG alone. The remainder may benefit from ICD placement or medical antiarrhythmic management.

Adult↗
PubMed1981

Cerebrospinal fluid and serum creatine kinase BB activity after out-of-hospital cardiac arrest.

In patients resuscitated from out-of-hospital cardiac arrest, neurologic outcome was compared with creatine kinase isoenzyme BB activity (CKBB) in cerebrospinal fluid (CSF) in 20 patients and in serum in 52 patients. CSF CKBB was 2 units per liter or less in patients with complete neurologic recovery but was significantly elevated in patients without neurologic recovery (mean, 55 units per liter) or with incomplete neurologic recovery (mean, 7 units per liter). Serum CKBB was detected more than 6 hours after cardiac arrest in only 4% of patients with complete neurologic but in all patients without neurologic recovery. These results demonstrate a relationship between CSF and serum CKBB and neurologic outcome after cardiac arrest.

Brain Injuries↗
PubMed2003

The epidemiology of cardiac arrest in children and young adults.

AIM: To describe the epidemiology of children and young adults suffering from out-of-hospital cardiac arrest. PATIENTS: All patients suffering from out-of-hospital cardiac arrest in whom, resuscitation efforts were attempted in the community of Göteborg between 1980 and 2000. METHODS: Between 31 October 1980 and 31 October 2000, all consecutive cases of cardiac arrest in which the emergency medical service (EMS) system responded and attempted resuscitation were reported and followed-up to discharge from hospital. RESULTS: Among 5505 cardiac arrests information on age was available in 5290 cases (96%). Of these 5290 cases 98 (2%) were children (age 0-17 years), 197 (4%) were young adults (age 18-35 years) and the remaining 4995 (94%) were adults (age >35 years). Children and young adults differed from adults by suffering from a witnessed arrest less frequently, being found by the ambulance crew in ventricular fibrillation/tachycardia less frequently and being judged as having an underlying cardiac aetiology less frequently. Of the children only 5% were discharged from hospital alive compared with 8% for young adults and 9% for adults. Among survivors the cerebral performance categories (CPC) score at discharge tended to differ with 38% of young adults registering a CPC score of 1 (no neurological deficit) compared with 52% among adults. CONCLUSION: Children and young adults suffering from out-of-hospital cardiac arrest differed from adults in terms of aetiology and observed initial arrhythmia. Children had a particularly bad outcome whereas young adults had a similar outcome as adults.

Adolescent↗
PubMed1994

Hemoconcentration during cardiac arrest and CPR.

The objective of this study was to determine if hemoconcentration occurs during cardiac arrest and cardiopulmonary resuscitation (CPR). The design was an animal model of cardiac arrest and CPR performed at a research institute using six mongrel dogs. After the induction of cardiac arrest, animals were subjected to 4 minutes of ventricular fibrillation followed by 20 minutes of CPR. Resuscitation was then achieved using countershocks, drugs, and intravenous fluids. Hemoglobin concentrations were obtained before arrest and every 5 minutes during CPR. An average peak increase in hemoglobin concentration of 21% was observed during CPR. Hemoconcentration occurs during cardiac arrest and CPR, and this may be a result of a shift in volume from the intravascular to the extravascular space.

Animals↗
PubMed1979

Prognosis after cardiac arrest occurring outside intensive care and coronary units.

Emergency calls to a total of 1686 patients with verified cardiac arrest in the University Hospital, Arhus, were made in the 8-year period 1969-1977. Among the patients, cardiac arrest occurred outside the hospital in 1347, in the general wards in 240, while it was present on arrival at the emergency room in 99. Resuscitation was attempted in 1172 patients; 181 survived for at least 24 hours, and 72 were discharged alive, including 13 with residual brain damage. The prognosis was best when cardiac arrest occurred in the general wards (13% discharged) and poorest when it occurred outside the hospital (4% discharged). However, in the latter group, the prognosis showed considerable improvement when resuscitation was initiated at once by a doctor or by laymen present at the accident site (16% discharged). As regards the mechanism of cardiac arrest, ventricular fibrillation was found to be a relatively favourable prognostic sign (10% discharged), whereas almost none of the patients with asystole or severe bradycardia survived. The possibility of improving the prognosis of cardiac arrest occurring outside hospital by the establishment of mobile coronary care units and by instructing lay people in the technique of cardiopulmonary resuscitation is discussed.

Adolescent↗
PubMed1995

Successful myocardial revascularization and neurologic recovery in a patient with prolonged refractory cardiac arrest and a chronically occluded left internal carotid artery.

Heretofore, the longest successfully treated cardiac arrest reported in the literature, secondary to myocardial ischemia, was one that required 45 minutes of cardiopulmonary resuscitation before coronary bypass surgery. We present a unique case of successful resuscitation after a cardiac arrest secondary to myocardial ischemia. The arrest lasted 78 minutes (30 minutes of closed cardiac massage and 48 minutes of open cardiac massage). As soon as a perfusionist was available, cardiopulmonary bypass was initiated. After completion of the distal anastomosis and upon removal of the aortic cross clamp, the patient spontaneously recovered sinus rhythm for the 1st time since her cardiac arrest 2 hours and 10 minutes earlier. This 70-year-old woman, with a history of chronic occlusion of the left internal carotid artery, recovered fully, without evidence of neurologic or myocardial insult. We believe that vigorous closed and open cardiac massage, followed by cardiopulmonary bypass and the correction of myocardial ischemia, enabled this patient to survive a prolonged refractory cardiac arrest.

Aged↗
PubMed2006

Early outcomes of out-of-hospital cardiac arrest after early defibrillation: a 24 months retrospective analysis.

INTRODUCTION: Cardiovascular disease remains the most common cause of death in the United States and most other Western nations. Among these deaths, sudden, out-of-hospital cardiac arrest claims approximately 1000 lives each day in the United States alone. Most of these cardiac arrests are due to ventricular fibrillation. Though highly reversible with the rapid application of a defibrillator, ventricular fibrillation is otherwise fatal within minutes, even when cardiopulmonary resuscitation is provided immediately. The overall survival rate in the United States is estimated to be less than 5 percent. Recent developments in automated-external-defibrillator technology have provided a means of increasing the rate of prompt defibrillation after out-of-hospital cardiac arrest. After minimal training, nonmedical personnel (e.g., flight attendants and casino workers) are also able to use defibrillators in the workplace, with lifesaving effects. Nonetheless, such programs have involved designated personnel whose job description includes assisting persons who have had sudden cardiac arrest. Data are still lacking on the success of programs in which automated external defibrillators have been installed in public places to be used by persons who have no specific training or duty to act. MATERIALS AND METHODS: All patients who had an out-of-hospital cardiac arrest between January 2003 and December 2004 and who received early defibrillation for ventricular fibrillation were included. We conducted a 24 months retrospective population-based analysis of the outcome in our population. RESULTS: Over a 24 month period, 446 people had non-traumatic cardiac arrest, and in all of them it was observed to be ventricular fibrillation. In a very few cases, the defibrillator operators were good Samaritans, acting voluntarily. Eighty-nine patients (about 19%) with ventricular fibrillation were successfully resuscitated, including eighteen who regained consciousness before hospital admission. CONCLUSION: Automated external defibrillators deployed in readily accessible, well-marked areas, are really very effective in assisting patients with cardiac arrest. However, it's quite true that, in the cases of survivors, most of our users had good prior training in the use of these devices.

Journal Article↗
PubMed1997

Population density, automated external defibrillator use, and survival in rural cardiac arrest.

OBJECTIVE: To determine whether population density is an independent predictor of survival from out-of-hospital cardiac arrest managed by basic life support (BLS) services using automated external defibrillators (AEDs). METHODS: A retrospective, observational study in Kentucky of 34 BLS services covering 22 counties during the years 1992 to 1994 who used AEDs to treat patients who had out-of-hospital cardiac arrests. RESULTS: Of 311 patients who had out-of-hospital cardiac arrests, 110 (35%) were defibrillated, 46 (15%) were resuscitated to hospital admission, and 19 (6%) survived to hospital discharge. Univariate predictors for survival to hospital discharge were emergency medical services response interval (from call receipt to ambulance arrival) < 8 minutes, defibrillation by the AED, initial rhythm of ventricular fibrillation or ventricular tachycardia (VF/VT), and population density > 100/square mile (sq mi) for the BLS service area (p < 0.001). A forced logistic regression model of survival to hospital discharge, using these 4 factors plus the presence of a witnessed arrest or bystander CPR, demonstrated that population density > 100/sq mi was highly significant (OR 9.4, 95% CI: 1.7 to 51.4, p < 0.01). Stepwise logistic regression models with combinations of these 6 factors found that survival to hospital discharge was best predicted by an initial rhythm of VF/VT (p = 0.004) and population density > 100/sq mi (p = 0.011). CONCLUSIONS: Population density is strongly associated with survival from out-of-hospital cardiac arrest. BLS services within areas with population densities < or = 100/sq mi sustained little benefit from the addition of AEDs to their treatment of patients who had out-of-hospital cardiac arrests.

Aged↗
PubMed2003

A survey of the in-hospital response to cardiac arrest on general wards in the hospitals of Rome.

OBJECTIVE: To investigate the response to cardiac arrest in general wards. METHODS: Direct interview with the cardiac arrest team (CAT) members in 32 hospitals in Rome, Italy. RESULTS: The majority of CATs are activated by telephone but only two (6%) hospitals have a dedicated telephone number for emergency calls. The CAT always includes a physician, who is usually an anaesthesiologist (30 hospitals, 94%), and usually includes one or two other members (23 hospitals, 72%). In 21 hospitals (65%) there is less than one defibrillator per floor but in only six hospitals (19%), CATs are equipped with defibrillators. Resuscitation guidelines are adopted by 15 teams (47%). The Utstein style of data collection is used in only one hospital. The most common problems reported by the CATs are: insufficient training of ward personnel (29 hospitals, 91%), insufficient staff (19 hospitals, 59%) and insufficient equipment (18 hospitals, 56%). Average maximum arrival time for the CAT to arrive is 220 s, but varies significantly between single-building and the multiple-building hospitals (88 vs. 390 s; P<0.001). CONCLUSIONS: The majority of the cardiac arrest teams have acceptable response times, but their efficiency may be impaired by the lack of staff, equipment and co-ordination with the ward personnel. CAT members identified a strong need for BLS training of ward personnel. More widespread introduction of standard protocols for resuscitation and reporting of cardiac arrest are necessary to evaluate aspects that may need improvement.

Data Collection↗
PubMed1988

A nurse-associated epidemic of cardiac arrests in an intensive care unit.

Review of 2219 admissions to an intensive care unit at a large urban hospital from 1983 to 1985 revealed an epidemic of cardiac arrests during the evening shift from January 1984 to March 1985. Of the 88 evening-shift cardiac arrests during this time, one specific nurse (Nurse 14) was the care giver for 57 (65%). Eight of ten epidemic-period patients who experienced shift-specific circadian recurrences of cardiac arrests were patients of Nurse 14. No therapeutic intervention and no other health care provider was as strongly associated with evening-shift cardiac arrests as was Nurse 14. Multiple logistic regression analysis demonstrated that when risk of cardiac arrest was adjusted for age, sex, severity of illness, and postoperative status, patients of Nurse 14 were 47.5 times more likely to experience arrest than were other nurses' patients. An expert determined that, compared with other nurses, the cardiac arrests among Nurse 14's patients were more likely to be consistent with unexplained hyperkalemia, to be unexpected in timing, and to be inconsistent with the clinical course. The epidemic ceased when Nurse 14 left employment at the intensive care unit in March 1985. Epidemiologic surveillance of adverse outcomes in health care settings is recommended.

Data Interpretation, Statistical↗