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Objectives: Recently, ILCOR unveiled the ground-breaking global initiative “Ten Steps Toward Improving In-Hospital Cardiac Arrest” (IHCA). Aim: To generate a baseline of how well the ten steps currently function in Sweden, in order to better target educational interventions. Material and methods: A survey was created using an online form application (Google Forms) and sent to CPR coordinators and physicians in charge of CPR at all 74 Swedish hospitals participating in the Swedish Registry for Cardiopulmonary Resuscitation (SRCR). Hospitals were asked to self-evaluate their functionality on each step on a ten-point scale ranging from 1 “Not present or not functioning at all” to 10 “Very well-functioning”. Data regarding number of IHCA and their survival during 2018–2022 was gathered from the SRCR. Results: A total of 34 out of 74 (46%) Swedish hospitals participated in the survey, collectively representing 59% (7,113 out of 12,070) of IHCA cases in SRCR. The responding hospitals were satisfied with the functionality of just over half of the steps currently (median 60%, range 30–90%). The steps with the highest proportion of satisfied hospitals were found for step 6-rapid response systems (85%) and 7-guideline-based resuscitation (94%), while the steps with lowest proportion of satisfied hospitals were found for step 4-goals of treatment (32%) and step 9-person centred culture (18%). About half of participating hospitals expressed intent to prioritise upcoming years’ work on step 1- infrastructure, step 3- effective education and step 5- stop preventable IHCA. Conclusion: The conclusion is that most hospitals judge themselves to be well-functioning on many of the ten steps, but steps involving effective education might need attention, as well as the tolerance for presence of preventable IHCA being low.

Aim: Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is time-dependent. To date, evidence-based training programmes for dispatchers are lacking. This study aimed to reach expert consensus on an educational bundle content for dispatchers to provide DA-CPR using the Delphi method. Method: An educational bundle was created by the Swedish Resuscitation Council consisting of three parts: e-learning on DA-CPR, basic life support training and audit of emergency out-of-hospital cardiac arrest calls. Thereafter, a two-round modified Delphi study was conducted between November 2022 and March 2023; 37 experts with broad clinical and/or scientific knowledge of DA-CPR were invited. In the first round, the experts participated in the e-learning module and answered a questionnaire with 13 closed and open questions, whereafter the e-learning part of the bundle was revised. In the second round, the revised e-learning part was evaluated using Likert scores (20 items). The predefined consensus level was set at 80%. Results: Delphi rounds one and two were assessed by 20 and 18 of the invited experts, respectively. In round one, 18 experts (18 of 20, 90%) stated that they did not miss any content in the programme. In round two, the scale-level content validity index based on the average method (S-CVI/AVE, 0.99) and scale-level content validity index based on universal agreement (S-CVI/UA, 0.85) exceeded the threshold level of 80%. Conclusion: Expert consensus on the educational bundle content was reached using the Delphi method. Further work is required to evaluate its effect in real-world out-of-hospital cardiac arrest calls.

Objectives: Staff in hospitals are encouraged to write up incident reports whenever they notice an incident. There are few published compilations of these reports from an in-hospital cardiac arrest (IHCA) perspective. Aim: To describe content of incident reports over ten years in a two-sited university hospital in order to share knowledge and thereby being able to improve resuscitation systems in hospitals. Material and methods: All incident reports between 2010–June 2023 written at Karolinska University Hospital contain the words “CPR”, “cardiac arrest”, “resuscitation”, Do-Not–attend-CPR” (DNACPR), “life-sustaining treatment” were included for analysis. Reports were grouped into larger themes. Results: In all 588 reports was identified automatically by the hospitals system based on the totally selected keywords. The largest category was “Life-sustaining treatment” with 178 (30%) reports and thereafter “Preventing care” (117, 20%) and “Material” (80, 14%). Conclusion: Our hospital has clearly valued incident reports as a mean to track on-going issues and serious events over time as well as a source to trigger educational interventions. To improve patient safety, a standardized approach for compilation of reports and actions would be helpful when sharing knowledge between hospitals and with the resuscitation community.

Objectives: Awareness of causes of cardiac arrest is essential to prevent them. A recent review found that almost every sixth in-hospital cardiac arrest is caused by infection. Few studies have explored how infections cause cardiac arrest. Aim: To describe the features, mechanisms and outcome of sepsis-related cardiac arrests. Material and methods: All patients ≥18 years who suffered a cardiac arrest at Karolinska University Hospital between 2007 and 2022 with sepsis as the primary cause were included. Data were collected the Swedish Registry for Cardiopulmonary Resuscitation and medical records. The primary outcome was survival to discharge. Results: Out of 2,327 in-hospital cardiac arrests, 5% (n = 123) suffered it due to sepsis, and 17% (21) survived to hospital discharge. Two thirds of patients were admitted to the hospital due to sepsis and suffered their cardiac arrest after a median of four days. About half (n = 59) had deranged vital signs before the event. Most were witnessed in general wards. In all, 47% (n = 58) had asystole and 24% (n = 30) as the first heart rhythm. The respiratory tract was the most common source of infection. Most patients were undergoing antibiotic therapy and one third had a positive microbiological culture with mixed gram-positive bacteria or Escherichia coli in the urine. Conclusion: Our results suggest that sepsis is an uncommon and not increasing cause of in-hospital cardiac arrest and its outcome is in line with other non-shockable cardiac arrests. Deranged respiratory and/or circulatory vital signs precede the event.

Background: Simulating CPR scenarios in a clinical environment has been described as a method for mitigating latent safety threats. Therefore, we implemented regular inter-professional, multidisciplinary in-situ simulations in the emergency department (ED). Aim: To iterate a line-up and action cards for initial CPR management. To examine the experiences among participants regarding attitudes towards simulation and if they perceived any benefits for their patients after the participation. Method: In 2021 we performed 7 in-situ simulations (15-minute simulation, 15-minute hot debrief) in the ED with the CPR team including doctors and nurses from the ED and anaesthesiology department. A questionnaire was sent to the 48 participants the same day and after 3 and 18 months. Answers were given as yes/no or on a Likert scale 0–5 and are presented as median values with interquartile range (IQR) or frequencies. Results: A line-up and 9 action cards were created. The response rate of the three questionnaires were 52, 23, and 43%, respectively. In total, 100% would recommend the in-situ simulation to a co-worker. Participants perceived that real patients (5 [3–5]) as well as themselves, (5 [3.5–5]), had benefited from the simulation up to 18 months after. Conclusion: Thirty-minute in-situ simulations are feasible to implement in the ED and simulation observations were useful for development of standardised role descriptions for resuscitation in the ED. Participants self-report benefit for themselves as well as their patients.

Introduction: Higher rates of mortality following an in-hospital cardiac arrest (IHCA) has been shown during nights and weekends, changes in staff density and composition has been suggested as a possible explanation. Changes in hospital staffing patterns are also common during holiday periods. Aim: To investigate whether holiday periods are associated with decreased survival following an IHCA. Material and methods: All patients ≥18 years who experienced an IHCA at Karolinska University Hospital between 2006 and 2019 were included. Patients were identified via and data was collected from the Swedish Registry for Cardiopulmonary Resuscitation. Holiday was defined as two periods, a seven-week summer period and an approximately two-week Christmas period. The primary outcome was return of spontaneous circulation (ROSC), secondary survival to hospital discharge. Logistic regression was performed to calculate odds ratio (OR) with 95% confidence intervals (CI), adjustment was done for known confounders. Results: Out of 1936 registered cases, 264 (14%) occurred during holiday periods. Patient and event characteristics were similar on holidays compared to non-holidays. Both ratio for ROSC (45% and 55%, respectively) and survival (25% and 32% respectively) was poorer during holiday periods Adjusted OR for ROSC and survival was poorer during holiday periods compared non-holiday periods (OR 0.69 [95% CI, 0.53–0.92] and OR 0.69 [95% CI, 0.49–0.96], respectively). Conclusion: Outcomes after IHCA was poorer during holiday periods compared to non-holiday periods even if patient and event characteristics was similar. Further research is needed to better understand to what degree staffing patterns and other factors contribute to the observed difference.

Aim: To conduct a systematic review of the use of the recovery position in adults and children with non-traumatic decreased levels of responsiveness changes outcomes in comparison with other positioning strategies. Methods: We searched Medline (Ovid), Embase, Cochrane Library, CINAHL, medRxiv and Google Scholar from inception to 15 March 2021 for studies involving adults and children in an out-of-hospital, first aid setting who had reduced levels of responsiveness of non-traumatic aetiology but did not require resuscitative interventions. We used the ROBINS-I tool to assess risk of bias and GRADE methodology to determine the certainty of evidence. Results: Of 17,947 citations retrieved, three prospective observational studies and four case series were included. The prone and semi-recumbent positions were associated with a decreased rate of suspected aspiration pneumonia in acute poisoning. Use of the recovery position in paediatric patients with decreased levels of responsiveness was associated with a deceased admission rate and the prone position was the position most commonly associated with sudden unexpected death in epilepsy. High risk of bias, imprecision and indirectness of evidence limited our ability to perform pooled analyses. Conclusion: We identified a limited number of observational studies and case series comparing outcomes following use of the recovery position with outcomes when other patient positions were used. There was limited evidence to support or revise existing first aid guidance; however, greater emphasis on the initial assessment of responsiveness and need for CPR, as well as the detection and management of patient deterioration of a person identified with decreased responsiveness, is recommended.

Aim: Early identification of patients at risk of serious adverse events (SAEs) is of vital importance, yet it remains a challenging task. We investigated the predictive power of National Early Warning Score (NEWS) 2, as compared to NEWS, among patients assessed by a Rapid response team (RRT). Methods: Prospective, observational cohort study on 898 consecutive patients assessed by the RRTs in 26 Swedish hospitals. For each patient, NEWS and NEWS 2 scores were uniformly calculated by the study team. The associations of NEWS and NEWS 2 scores with unanticipated admissions to Intensive care unit (ICU), mortality and in-hospital cardiac arrests (IHCA) within 24 h, and the composite of these three events were investigated using logistic regression. The predictive power of NEWS and NEWS 2 was assessed using the area under the receiver operating characteristic (AUROC) curves. Results: The prognostic accuracy of NEWS/NEWS 2 in predicting mortality was acceptable (AUROC 0.69/0.67). In discriminating the composite outcome and unanticipated ICU admission, both NEWS and NEWS 2 were relatively weak (AUROC 0.62/0.62 and AUROC 0.59/0.60 respectively); for IHCA the performance was poor. There were no differences between NEWS and NEWS 2 as to the predictive power. Conclusion: The prognostic accuracy of NEWS 2 to predict mortality within 24 h was acceptable. However, the prognostic accuracy of NEWS 2 to predict IHCA was poor. NEWS and NEWS 2 performed similar in predicting the risk of SAEs but their performances were not sufficient for use as a risk stratification tool in patients assessed by a RRT.

Aims: The aims were to examine patient and hospital characteristics associated with Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) decisions for adult admissions through the emergency department (ED), for patients with DNACPR decisions to examine patient and hospital characteristics associated with hospital mortality, and to explore changes in CPR status. Methods: This was a retrospective observational study of adult patients admitted through the ED at Karolinska University Hospital 1 January to 31 October 2015. Results: The cohort included 25,646 ED admissions, frequency of DNACPR decisions was 11% during hospitalisation. Patients with DNACPR decisions were older, with an overall higher burden of chronic comorbidities, unstable triage scoring, hospital mortality and one-year mortality compared to those without. For patients with DNACPR decisions, 63% survived to discharge and one-year mortality was 77%. Age and comorbidities for patients with DNACPR decisions were similar regardless of hospital mortality, those who died showed signs of more severe acute illness on ED arrival. Change in CPR status during hospitalisation was 5% and upon subsequent admission 14%. For patients discharged with DNACPR decisions, 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. Conclusion: For a mixed population of adults admitted through the ED, frequency of DNACPR decisions was 11%. Two-thirds of patients with DNACPR decisions were discharged, but one-year mortality was high. For patients discharged with DNACPR decisions, reversal of DNACPR status was substantial and this should merit further attention.

Objectives: Pulmonary embolism (PE) constitutes one of the reversible causes of cardiac arrest. The prognosis for PE-related cardiac arrest is poor. Some previous studies have suggested a higher survival rate in patients with PE-related cardiac arrest who receive thrombolysis. No such study has focused on in-hospital cardiac arrests (IHCA). Aim: To describe the prevalence of PE-related IHCA and the characteristics of those patients, as well as to describe favourable and adverse outcomes after thrombolysis. Material and methods: All patients ≥ 18 years who experienced an IHCA at Karolinska University Hospital between 2007 and 2020 with PE as the primary cause of IHCA were included. Patients were identified from the Swedish Registry for Cardiopulmonary Resuscitation (SRCR). Data was collected from the SRCR and medical records. The primary outcome was survival to discharge. Secondary outcomes were alive at the end of CPR, major bleeding, and minor bleeding. Results: Out of 2,128 IHCA patients, 64 (3%) had a PE-related IHCA of whom 16 (25%) had thrombolysis. A significant association was seen between thrombolysis and survival to discharge (44 % vs 8 %, p-value

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.

The aim of this article is to describe current Swedish legalisation, clinical practice and future perspectives on the medical ethical decision “Do-Not-Attempt-Cardio-Pulmonary-Resuscitation” (DNACPR) in relation to prevent futile resuscitation of in-hospital cardiac arrests. Sweden has about 2200 in-hospital cardiac arrests yearly, with an overall 30-day survival ratio of 35%. This population is highly selected, although the frequency of DNACPR orders for hospitalized patients is unknown, resuscitation is initiated in only 6–13% of patients dying in Swedish hospitals.According to Swedish law and although shared decision making is sought, the physician is the ultimate decision-maker and consultation with the patient, her relatives and another licenced health care practitioner is mandatory. According to studies, these consultations is documented in only about 10% of the decisions. Clinicians lack tools to assess risk of IHCA, tools to predict outcome and we are not good at guessing patients own will.Future directives for clinical practice need to address difficulties for physicians in making decisions as well as the timing of decisions.We conclude that the principles in Swedish law needs to be fulfilled by a more systematic approach to documentation and planning of meetings between patients, relatives and colleagues.