Oregon Health & Science University, Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098, USA.
Resuscitation. 2013 Apr;84(4):483-7. doi: 10.1016/j.resuscitation.2012.08.327. Epub 2012 Aug 30.
Among patients successfully resuscitated from out-of-hospital cardiac arrest (OHCA) and admitted to California hospitals, we examined how the placement of a do not resuscitate (DNR) order in the first 24h after admission was associated with patient care, procedures and inhospital survival. We further analyzed hospital and patient demographic factors associated with early DNR placement among patients admitted following OHCA.
We identified post-OHCA patients from a statewide California database of hospital admissions from 2002 to 2010. Documentation of patient and hospital demographics, hospital interventions, and patient outcome were analyzed by descriptive statistics and multiple regression models to calculate odds ratios and 95% confidence intervals.
Of 5212 patients admitted to California hospitals after resuscitation from OHCA, 1692 (32.5%) had a DNR order placed in the first 24h after admission. These patients had decreased frequency of cardiac catheterization (1.1% vs. 4.3%), blood transfusion (7.6% vs. 11.2%), ICD placement (0.1% vs. 1.1%), and survival to discharge (5.2% vs. 21.6%, all p-values<0.0001). There was wide intrahospital variability and significant racial differences in the adjusted odds of early DNR orders (Asian, OR 0.67, 95% CI 0.48-0.95; Black, OR 0.49, 95% CI 0.35-0.69).
Early DNR placement is associated with a decrease in potentially critical hospital interventions, procedures, and survival to discharge, and wide variability in practice patterns between hospitals. In the absence of prior patient wishes, DNR placement within 24h may be premature given the lack of early prognostic indicators after OHCA.
在成功复苏院外心脏骤停（OHCA）并入院加州医院的患者中，我们研究了入院后 24 小时内放置不复苏（DNR）医嘱与患者治疗、程序和院内存活率的关系。我们进一步分析了与 OHCA 后入院患者早期放置 DNR 相关的医院和患者人口统计学因素。
我们从 2002 年至 2010 年全州加利福尼亚州医院入院数据库中确定了 OHCA 后患者。通过描述性统计和多元回归模型分析患者和医院人口统计学、医院干预和患者结局，计算比值比和 95%置信区间。
在从 OHCA 复苏后入院加州医院的 5212 名患者中，1692 名（32.5%）在入院后 24 小时内下达了 DNR 医嘱。这些患者接受心脏导管插入术的频率降低（1.1% vs. 4.3%）、输血（7.6% vs. 11.2%）、ICD 放置（0.1% vs. 1.1%）和出院存活（5.2% vs. 21.6%，所有 p 值均<0.0001）。早期 DNR 医嘱的调整后比值存在广泛的院内变异性和显著的种族差异（亚洲人，OR 0.67，95%CI 0.48-0.95；黑人，OR 0.49，95%CI 0.35-0.69）。
早期 DNR 医嘱的下达与潜在关键医院干预、程序和出院存活的减少相关，并且医院之间的实践模式存在广泛的变异性。在 OHCA 后缺乏早期预后指标的情况下，24 小时内下达 DNR 医嘱可能为时过早，因为缺乏先前的患者意愿。
