Background for Fast Fact #179     Approximately 290,000 in-hospital cardiopulmonary arrests leading to cardiopulmonary resuscitation (CPR) attempts occur each year in the United States. Survival to discharge following cardiac arrest occurring in the hospital is infrequent and roughly estimated to be between 15-25% in most studies (for comparison survival to discharge of out-of-hospital CPR attempts is estimated to be 10-12%) (1). This Fast Fact will review keystone data on CPR outcomes in hospitalized patients. 

I. A report of in-hospital CPR outcomes from the National Registry of Cardiopulmonary Resuscitation, reported data from 14,720 resuscitation attempts in adults from 207 U.S. hospitals (2).  The uniform case inclusion definition included cardiac and respiratory arrests requiring an emergency response.

• Survival 20 minutes after CPR was 44%, but only 17% of all CPR patients survived to discharge.   The survival to discharge for ventricular fibrillation and pulseless ventricular tachycardia was 34% and 35%, respectively, but only 10% for asystole and pulseless electrical activity. Unfortunately, though, less than 20% present with a non-shockable rhythm (1).
• Pre-CPR, 84% came from home. Among survivors, 51% returned home; 46% were discharged to another hospital, a rehabilitation facility, or a nursing home; 2% were discharged to hospice care.
• Neurological function of survivors was assessed using a five-point scale (1 = good performance to 5 = brain death). Pre-CPR, 68% were in category 1, falling to 59% at discharge. In other words, 86% of category 1 patients remained at this level if they survived CPR, whereas 14% had neurological decline.
• Overall functional performance was assessed using a similar five-point scale (1 = good to 5 = brain death).  Overall performance declined:  49% of survivors were category 1 pre-CPR compared to only 37% after CPR, a 25% decline in overall function.

II. A meta-analysis of data from 49 publications after 1980, totaling 9,838 patients (3). 

• Depending on the rigor of CPR event definition, immediate survival was 41-44% and survival to discharge was 13-15%.
• Of the five studies reporting discharge information, 78% of 93 survivors returned to their home.
• Factors associated with survival to discharge were myocardial infarction, coronary heart disease, and hypertension.
• Factors predicting a failure to survive to discharge:
  • Sepsis the day prior to the CPR event
  • Serum creatinine >1.5 mg/dl
  • Dependency for activities of daily living
  • Hypotension on admission
  • Metastatic cancer
  • Dementia

III. The American Heart Association (AHA) published a consensus statement reviewing in-hospital cardiac arrest results in the US (4).  Major take-home points were:  

• There is a lack of consistency with how investigators report survival after inpatient CPR. Some studies exclude patients made DNR after the CPR attempt from data analysis, others do not.
• Regardless, survival to hospital discharge has remained essentially unchanged for decades.
• Despite the rising prevalence of “rapid response teams”, there is no convincing evidence these teams have improved survival rates.  Rather, these teams likely spare the need for non-ICU CPR attempts via earlier identification of critically ill patients and more efficient ICU transfer.

IV. Historically, the CPR success rate in patients with cancer has been thought to be less than 2%.  A meta-analysis of 42 studies from 1966-2005 suggests that 6.7% of cancer patients (localized: 9.1%; metastatic: 5.6%) survived CPR to discharge (5).  Survival to discharge for ward patients was better than ICU patients: 10.1% vs.2.2%. In subsequent studies, cancer was associated with a 3.9 odds ratio of failing to survive to discharge after CPR compared to patients without cancer (6).

V. Patients receiving dialysis: multiple studies have looked at CPR outcomes in patients receiving dialysis.  Survival to discharge was seen in 14% of patients.  One study examined long-term survival: of 74 patients undergoing CPR, only 2 (3%) survived six months (vs. 9% of non-dialysis controls) (8).

Summary     CPR for hospitalized patients is associated with poor outcomes, as the cause of arrest is usually associated with advanced chronic illness rather than an easily reversible acute cardio-pulmonary event (e.g. isolated arrhythmia).  The AHA recommends the widespread use of advance directive for all patients admitted to the hospital as well as “frank” discussions about prognosis and survival rates from CPR.  When talking with patients about CPR, physicians can say roughly 15%, or 1 in 6 patients, who undergo CPR in the hospital survive to discharge.  However, specific co-morbidities will reduce the chance of survival, and surviving patients are at risk for a range of CPR-related complications including permanent neurological and functional impairment.

References 

1. Andersen LW, Homberg MJ, Berg KM, et al.  In-hospital cardiac arrest: a review. JAMA 2019; 321(12):1200-10.
2. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: A report of 14,720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003; 58 297-308.
3. Ebell MH, et al. Survival after in-hospital cardiopulmonary resuscitation: a meta-analysis.   J Gen Int Med. 1998; 13(12):805-16.
4. Meaney PA, Bobow BJ, Mancini ME, et al.  Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation 2013; 128(4):417-35.
5. Zafari AM, Zarter SK, Heggen V, et al. A program encouraging early defibrillation results in improved in-hospital resuscitation efficacy. J Am Coll Cardiol.  2004; 44(4):846-852.
6. Ebell MH, Afonso AM.  Pre-arrest predictors of failure to survive after in-hospital cardiopulmonary resuscitation: a meta-analysis. Fam Pract 2011; 28(5):505-15.
7. Reisfield GM, et al. Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis. Resuscitation. 2006; 71:152-160.
8. Hijazi F, Holley JL. Cardiopulmonary resuscitation and dialysis: outcome and patients’ views.   Seminars in Dialysis. 2003; 16(1):51-53.
9. Morrison LJ, Neumar RW, et al.  Strategies for improving survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations; a consensus statement from the American Heart Association. Circulation 2013;127:1538-1563.

Version History:  Version re-copy-edited in May 2009; revised again in July 2015 by Sean Marks; revised again in February 2025.
Conflicts of Interest: None to report.