Volume 27, Issue 3 (10-2017)                   J Holist Nurs Midwifery 2017, 27(3): 1-7 | Back to browse issues page

DOI: 10.18869/acadpub.hnmj.27.3.1

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Amini S, Moghadamnia M T, Paryad E, Kazem Nezhad Leyli E. Factors Associated with Survival Rate after Cardiopulmonary Resuscitation . J Holist Nurs Midwifery. 2017; 27 (3) :1-7
URL: http://hnmj.gums.ac.ir/article-1-911-en.html

MSN Social Determinants of Health Research Center (SDHRC), Instructor, Guilan University of Medical Sciences, Rasht, Iran , Moghadamnia@gums.ac.ir
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Factors Associated with Survival Rate after Cardiopulmonary Resuscitation
Sanaz Amini1, Mohammad Taghi Moghadamnia2*, Ezzat Paryad2, Ehsan Kazem Nezhad Leyli3
1Nursing(MSN), Heshmat Educational – Medical Center, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
2Social Determinants of Health Research Center (SDHRC), Instructor, Guilan University of Medical Sciences, Rasht, Iran
3Social Determinants of Health Research Center (SDHRC), Bio-Statistics, Associate Professor, Guilan University of Medical Sciences, Rasht, Iran
*Corresponding author: Mohammad Taghi Moghadamnia, School of Nursing and Midwifery, Rasht
E-mail: Moghadamnia@gums.ac.ir                              
Received: 20/08/2015; Accepted:  26/12/2015
Introduction: Cardiovascular disease is considered as the most important cause of mortality among men and women throughout the world. This condition causes sudden cardiac arrest in more than half of the cases. To reduce mortality due to this disease, cardiopulmonary resuscitation (CPR) and the determinants of its success are the focus of researchers.
Objective: The aim of this study was to determine the survival rate of CPR and its associated factors in patients with in-hospital cardiac arrest in a teaching medical center in Rasht.
Materials and Methods: The present descriptive-analytic cross-sectional study investigated 100 patients undergoing CPR during spring-summer 2014 at Specialized Cardiology Center in Rasht. The instrument of this study was the standard checklist of Utstein-Style that included information on age, gender, cause of cardiac arrest, rhythm, work shift, CPR place, interval of cardiac arrest until arrival of CPR team, interval of cardiac arrest until shock, interval of cardiac arrest until intubation, interval of cardiac arrest until CPR termination, short-term and long-term outcomes of CPR, and brain function status until discharge from the hospital. Data was analyzed using descriptive statistics (mean, standard deviation) and analytic analyses (T-test,  Fisher’s exact test, analysis of variance, and logistic regression).
Results: A total of 53% of subjects were male and mean age of the patients was 68.6 ± 14.4 years; 30% of patients who underwent CPR had short-term survival, and 11% were discharged with appropriate brain status with Glasgow Coma Scale (GCS=15). Multiple logistic regression (Backward LR method) revealed that only gender (p=0.008, OR=6.46, CI95%: 1.63-25.5) and electric shock (p=0.03, OR=4.1, CI95%: 1.1-15.14) were statistically significant predictors of short-term survival.
Conclusion: According to the results of this study, time is an important factor in CPR outcome and increasing the survival rate and timely use of electric shock can be an effective measure in shockable rhythms. Appropriate planning, training staff, and using appropriate facilities, as well as establishment of a primary warning system for calling CPR team in health centers can increase the success rate of CPR.
Keywords: Heart Arrest, Cardiopulmonary Resuscitation, Survival Rate, Inpatients
Please cite this article as: Amini S, Moghadamnia MT, Paryad E, Kazem Nejad Leili E; Factors Associated with Survival Rate after Cardiopulmonary Resuscitation.J Holist Nurs Midwifery. 2017;27(3):1-7

Cardiovascular disease is considered as one of the most important factors of mortality in the world [1]. It leads to sudden cardiac arrest in more than half of cases [2]. The incidence of in-hospital cardiac arrest due to heart disease is on the increase [3]. Given that the final presentation of many patients with heart disease is death, considering Cardio Pulmonary Resuscitation (CPR) and determinants of its success is the focus of researchers to reduce mortality rate of these diseases [4]. According to the National Registration Center for cardiopulmonary resuscitation in the United States, about 370,000-750,000 in-hospital CPRs are performed annually [5]. The number of patients admitted to the specialized cardiac teaching center which is a referred hospital since April to December 2013 was 8272 cases, including 169 CPR cases.
 Unfortunately, despite high frequency of CPRs, the survival rate does not seem to be proper [6]. About 25 to 67% of patients die within 24 h after CPR, even with successful CPR [5]. In developed countries, the in- and out-patient survival rate of cardiopulmonary arrest were less than 30 and 10%, respectively [7]. The success rate of CPR in Iran is reported to be 10 - 18% [8]. In the study by Salari et al, it was shown that only 7.2% of patients were discharged alive from the hospital after resuscitation, only 2.8% of whom had good brain function [6]. In the study by Krittayaphong et al., spontaneous return of circulation was 49.8% and survival until discharge was 7.4% [9]. In another study by Setayesh et al at a hospital affiliated to Tehran University of Medical Sciences, Iran, the results revealed that the percentage of successful CPR was high in this study, but compared to the statistics in other studies, only a few number were alive after resuscitation procedure [10]. Different researches have identified different factors as predictors of CPR outcome, expressed with diverse intensities [4, 6, 11-13].
In many studies, patient-related variables play very important roles in the success rate of CPR, including age [5, 13-15], and gender [5,13] and some studies, in addition to patient-associated variables, have suggested incident-related variables, such as interval of cardiac arrest until CPR [2, 5, 16], initial cardiac rhythm [4, 5, 10, 13, 17, 18], duration of the intervention period [5, 13], location of cardiac arrest in the hospital [5 , 19], time of CPR [5, 8].
Considering various factors affecting CPR outcome with different effects [9] and also the role of physical environment, equipment, and human resources in CPR outcome, as well as few studies on survival rate after in-hospital CPR, we aimed to study the determinants of survival rate after CPR, and related factors in patients with in-hospital cardiac arrest. Considering the role of physical and environmental factors on outcome, the findings of this research can shed light on predictive value of each of these factors and help provide appropriate solutions to improve CPR outcomes.
Materials and Methods
This descriptive cross-sectional study was on the survival rate after CPR, and factors associated with in-hospital cardiac arrest during spring and summer 2014 in specialized cardiac center of Rasht Teaching Medical Center. After approval by the Ethics Committee of Guilan University of Medical Sciences (06/02/2014, by the code: 2930111202), out of 192 CPRs performed during the study period, 100 cases were included in the present study based on convenient sampling method. The inclusion criteria for this study included patients with in-hospital cardiac arrest, GCS>14 at arrival, as well as patients without history of CPR. The sample size was calculated at 100, to determine the survival-associated factors, based on the study by Krittayaphong et al. [9], which showed survival rate of 21% after CPR, with a probability of 95% and power of 90%.
The research environment included cardiac and intensive care units, emergency department, and internal-cardiac ward of Rasht Teaching Medical Center. The instrument used in this study was the standard international checklist for CPR, Utstein-Style, used previously in an Iranian study by Salari et al. [6]. The collected data includes three parts: the patient-related factors, such as age, sex, cause of cardiac arrest, and heart rhythm; the incident-related factors, such as work shift, and CPR place; and time-related factors, such as interval of cardiac arrest until arrival of CPR team, interval of cardiac arrest until shock, interval of cardiac arrest until intubation, interval of cardiac arrest until CPR termination, the short- and long-term outcomes of CPR, and brain function status until discharge from the hospital. Results of CPR were considered unsuccessful (death of the patient) in less than 20 min from CPR onset; short-term survival was considered as spontaneous return of circulation from 20 min until 24 h after CPR; and long-term survival was considered from the second 24 h until discharge. For data collection, the researcher referred to patients after
CPR announcement (performed by the present personnel) and recorded initial heart rhythm of the patient, the cause of cardiopulmonary arrest, interventions before the arrival of CPR team, time of CPR onset, and the first shock, time and cause of CPR termination, announced by CPR leader team, a resident cardiac specialist. Demographic information of patients were extracted from medical records and in patients with spontaneous circulation return, the time of circulation return and patient’s condition until discharge were recorded. If the patient was discharged from the hospital alive, the neurologic status (GCS) and brain function were evaluated. Given that the researchers might have not been present in the hospital at all hours of CPR, two other persons were educated to collect data, and the consistency between the three were estimated, using Pearson correlation coefficient, showing correlation of more than 96%.
Data was analyzed by SPSS software Version 16 using descriptive [mean, standard deviation (SD)], and analytic tests (Independent T-test, Fisher, and logistic regression by Backward LR multiple logistic method, and input and output of variables at 0.05, and 0.1, respectively).
Results of this study showed that mean age of the studied patients was 68.6 ± 14.4 years with an age range of 20 to 93 years; 51% of CPR cases occurred at night.
Table 1. Frequency of cardiopulmonary resuscitation results based on the interval between cardiac arrest until CPR termination
Interval (min)
Unsuccessful CPR Successful CPR until the first 24 hours Sig* Unsuccessful CPR The second 24 hours until discharge Sig*
Interval of cardiac arrest until CPR termination 48.43 36.57 0.019 47.19 26.09 0.001
Interval of calling CPR team until CPR termination 47.94 34.87 0.002 46.30 25.55 0.001
Interval of CPR start until CPR termination 45.47 32.6 0.003 43.84 23.55 0.001
*T test
Table 2. Frequency and distribution of cardiopulmonary resuscitation results in terms of gender, time, and place, witnessed cardiac arrest, heart rhythm, and electric shock
Unsuccessful CPR (%) Successful CPR until the first 24 hours (%) CPR of the second 24 hours until discharge (%) Sig*
Sex Male 56.6 43.4 17 0.042
Female 85.1 14.9 4.3
Work shift Morning 77.3 22.7 13.6 0.891
Afternoon 66.7 33.3 11.1
Night 69.6 31.4 9.8
Place of cardiac arrest CCU 83.3 16.7 6.7 0.623
Emergency 65 35 13.3
Internal cardiac ward 60 40 10
The cause of cardiopulmonary arrest Coronary heart disease 67.5 32.5 12 0.746
Respiratory 81.3 18.8 6.3
Witnessed cardiac arrest Yes 76.8 23.2 6.1 0.001
No 38.9 61.1 33.3
Cardiac rhythm Ventricular fibrillation 40.9 59.1 22.7 0.98
Ventricular tachycardia without pulse 80 20 0
Brady-asystole 77.9 22.1 8.8
Electric shock Yes 56 44 16 0.078
No 74.7 25.3 9.3
Age (mean±SD) 69.11±15.30 67.33±12.26 66.73±12.05 0.654
*Fisher Exact Test
The majority of CPRs were performed in the emergency department (60%). The cause of cardiac arrest was coronary heart disease in 84% of cases. The primary heart rhythm was Brady-asystole in the most of the patients studied (68%). In terms of interventions, chest compression was carried out in 69% of cases. In terms of advanced interventions during CPR, access to peripheral veins and intubation were performed in 99% of cases. Based on the results of the study, the interval of cardiac arrest until CPR start was 2.46 ± 1.64 min, interval of announcing CPR until arrival of
CPR team was 2.1 ± 1.44 min, interval of cardiac arrest until announcing CPR was 0.45 ± 0.91 min, and the interval of cardiac arrest until end of CPR was 44.87 ± 20.03 min. Table 1 shows the distribution of CPR results according to time intervals of cardiac arrest until end of CPR.
Among those undergoing CPR, 30% had a short-term survival, and 11% were discharged from the hospital with a good brain condition and GCS>15. Table 2 shows the distribution and frequency of short- and long-term CPR outcome, based on sex, time, and place, witnessed cardiac arrest, cardiac rhythm, and electric shock.

Table 3. Predictive factors of cardiopulmonary resuscitation in patients with short-term survival
B SE Sig OR CI 95% for OR
Lower Upper
Male sex 1.89 0.7 0.008 6.46 1.63 25.51
Electric shock 1.4 0.66 0.035 4.1 1.1 15.14
Results -1.53 1.05 0.14 0.21    
* T test

Predictors of short-term survival after CPR are presented in Table 3 based on multiple logistic regression (Backward LR method) with the input and output of variables equal to 0.05, and 0.1, respectively. The low number of survival until discharge minimized the assessment of long-term predictive factors in this group.
Overall, the results of this study showed that the survival rate was 30% and long-term survival was 11%, and all of them had good brain function. A study on this issue by Goldberger et al reported the rate of spontaneous circulation return in 48.5% and survival to discharge of 15.4% [12]. Song et al studied patients with in-hospital cardiac arrest and reported spontaneous circulation return and hospital discharge of 47 and 13.5%, respectively [20]. In the study by Salari et al, 28.4% of CPRs had short-term success and of these, only 7.2% had long-term survival after CPR and were discharged from hospital [6]. Comparing the number of successful and unsuccessful CPRs in various studies indicated the failure of CPR in most cases in all areas. It seems that CPR fails despite the impact of human factors, equipment, and drugs, although the patient's underlying disease, skills of CPR team, and the cause of cardiac arrest can also affect the success rate of CPR.
Evaluation of the effect of gender on CPR outcome showed that men had higher circulation return in the first 24 h after CPR and higher survival to discharge.
However, Gershengorn et al. stated no significant relationship between sex and survival rate [21]. There seems to be no significant difference in CPR outcome between the two sexes and the significant difference in this study could be attributed to differences in the number of male and female patients.
According to the results, patients with witnessed cardiac arrest had higher short- and long-term chance of survival, which is in line with the results of several studies [6, 9] and underlie the fact that less time may be wasted to initiate primary survival care, CPR, and advanced life-saving measures in patients with witnessed cardiac arrest.
In this study, ventricular fibrillation had the highest frequency of the initial heart rhythm in successful CPR patients. The results of this study is consistent with the results of the study by Keyvan Pajouh et al. [8]. Another study by Salari et al. concluded that the survival rate of shockable rhythms was significantly higher than non-shockable rhythms with a significant relationship between the type of primary cardiac rhythm and shockability with CPR outcome [6]. In patients with Ventricular Fibrilation (VF), Ventricular Tachycardia (VT) without pulse, who respond quickly to electric shock and defibrillation, using this method can increase the chance of survival.
Considering factors predicting successful CPR during the first 24 h, only gender and electric shocks were statistically
significant predictors of short-term CPR, and the survival rate of men was 4.6 times greater than women, and electrical shock improved the chances of survival by 4.1 times. Similarly, Krittayaphong et al showed that female sex could predict cardiac arrest with shockable cardiac rhythms as the predictor of CPR outcome [9]. Considering that in this study, the highest rhythm observed was Brady-asystole, while in their study, most patients suffered from cardiac arrest due to Ventricular Fibrillation (VF) and Ventricular Tachycardia (VT), this difference in the cause of cardiac arrest could justify the difference in predicting CPR result.
In assessing the neurological status of patients who survived in the second 24 h until discharge, the results of this study showed that all patients were discharged with a GCS=15 and a good brain condition. Sandroni et al stated in their study that patients undergoing CPR in hospital are discharged with good brain function which is in line with the results of this study [5]. It seems that this good brain function in the patients studied in the present study is due to the rapid onset of initial life-saving measurements and rapid arrival of CPR team, which led to a reduction in brain hypoxia and associated damage.
The results of this study indicate the important role of time on CPR outcome, as well as the effect of timely use of electric shocks in increasing the survival rate, thus, reasonable planning, training the staff, and using appropriate facilities and warning system for calling CPR team at health centers can increase the success rate of CPRs. Also, due to the large difference between CPR rate within the first 24 h and the successful CPR until discharge, which indicate the death of some patients after the initial CPR, special attention should be paid to post-CPR care.
This article is the results of an approved project at Social Determinants of Health Research Center (SDHRC) and the Department of Research and Technology of Guilan University of Medical Sciences and part of a master's degree in nursing. The authors express their appreciation to the Research Center, as well as the Hospital officials of Dr. Heshmat Medical Center for their kind cooperation with the researchers.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recommendations/): -Substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data;
-Drafting the article or revising it critically for important intellectual content
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Article Type : Research | Subject: Special
Received: 2017/09/23 | Accepted: 2017/09/23 | Published: 2017/09/23

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