Cardiac arrest in the intensive care unit: An assessment of preventability

Abstract

Aim: Cardiac arrest in the intensive care unit (ICU-CA) is a common and highly morbid event. We investigated the preventability of ICU-CAs and identified targets for future intervention.

Methods: This was a prospective, observational study of ICU-CAs at a tertiary care center in the United States. For each arrest, the clinical team was surveyed regarding arrest preventability. An expert, multi-disciplinary team of physicians and nurses also reviewed each arrest. Arrests were scored 0 (not at all preventable) to 5 (completely preventable). Arrests were considered 'unlikely but potentially preventable' or 'potentially preventable' if at least 50% of reviewers assigned a score of ≥1 or ≥3 respectively. Themes of preventability were assessed for each arrest.

Results: 43 patients experienced an ICU-CA and were included. A total of 14 (32.6%) and 13 (30.2%) arrests were identified as unlikely but potentially preventable by the expert panel and survey respondents respectively, and an additional 11 (25.6%) and 10 (23.3%) arrests were identified as potentially preventable. Timing of response to clinical deterioration, missed/incorrect diagnosis, timing of acidemia correction, timing of escalation to a more senior clinician, and timing of intubation were the most commonly cited contributors to potential preventability. Additional themes identified included the administration of anxiolytics/narcotics for agitation later identified to be due to clinical deterioration and misalignment between team and patient/family perceptions of prognosis and goals-of-care.

Conclusions: ICU-CAs may have preventable elements. Themes of preventability were identified and addressing these themes through data-driven quality improvement initiatives could potentially reduce CA incidence in critically-ill patients.

Keywords: Cardiopulmonary resuscitation; Critical care; Heart arrest; Intensive care unit quality improvement.

Fig. 1 −

Preventability scale.

Fig. 2 −

Themes of preventability as determined by the expert panel. The number of arrests in which at least one expert review identified the contributor to arrest preventability. Only contributors identified in at least one arrest are included in this graph to allow for readability. Solid color bars represent a priori defined contributors and speckled bars represent novel contributors identified during expert review of the cases. Only ICU-CAs identified as at least ‘unlikely but potentially’ preventable are included.