https://orcid.org/0000-0003-4887-3487
Figures
Abstract
Introduction
Cardiopulmonary resuscitation (CPR) is an evidence-based intervention that saves lives. In low- and middle-income countries like Nepal, the occurrence of the problem and its outcome are seldom studied. The study aims to highlight the prevalence, performance, and outcome of CPR in government hospitals of Nepal.
Methods
A mixed method study was done for two months in central and provincial government hospitals of Nepal. A total of 80 resuscitations were evaluated using a questionnaire based on the American Heart Association 2020 guidelines for cardiopulmonary resuscitation. An in-depth interview was conducted with 15 active participants of the resuscitation in different sites. Thematic analysis was done using the framework of the chain of survival of arrest victims.
Results
The overall prevalence of CPR was found to be 1.92% [95% CI: 0.01,0.02] with 5.4% in central hospitals and 0.65% in provincial hospitals with 60% cardiac arrests occurring in the intensive care unit. Estimated time from recognition of the arrest to initiating CPR was 1.9 ±1.4 minutes. Asystole 66.25% was the commonest arrest rhythm and 21.25% had difficulty interpreting rhythm. Only 11.25% of the victims had return of spontaneous circulation and were subsequently transferred for post-arrest care. The qualitative analysis highlighted the lack of trained staff, a dedicated system, feedback mechanism, and provision of post-arrest care.
Conclusion
Across various level of Nepal’s healthcare system, cardiopulmonary resuscitation is prevalent with poor performance and outcome. To improve outcomes, it is essential to implement standardized procedures and ensure high quality resuscitation delivery before and after the event supported by well-trained healthcare personnel and adequate infrastructure.
Citation: Hamal PK, Kunwar S, Gautam K, Bhattarai R, Yadav RK, Lamsal R, et al. (2025) Prevalence, outcome and conduct of in-hospital cardiopulmonary resuscitation in government hospitals of Nepal. PLoS ONE 20(1): e0316950. https://doi.org/10.1371/journal.pone.0316950
Editor: Sebastian Schnaubelt, Medical University of Vienna, AUSTRIA
Received: July 10, 2024; Accepted: December 18, 2024; Published: January 31, 2025
Copyright: © 2025 Hamal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data files are available in the Figshare Repository at: https://doi.org/10.6084/m9.figshare.27154473.v1.
Funding: Provincial Health Research Grant 2021 was received from Nepal Health Research Council The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interest exist.
Introduction
Cardiopulmonary resuscitation (CPR) is a cost-effective intervention that saves lives. The reported incidences of In-hospital cardiac arrest (IHCA) vary globally, ranging from 1.2–9 per 1000 admissions [1]. Specifically, the DANARREST (Danish in-hospital cardiac arrest registry) nationwide registry reports prevalence of 1.8 per 1000 admission [2], Japan reports 5.1 per 1000 hospital admission [3], the Get-With-The-Guidelines-Resuscitation (GWTG-R) reports 9.7 per 1000 hospital admissions in USA [4] and UK National Cardiac Arrest Audit (NCAA) reports 1–1.6 per 1000 admissions [5]. In study done in Uganda, IHCA was found to be 2.3% with return of spontaneous circulation (ROSC) in 7.4% cardiac arrest [6]. Arrest Outcome Consortium Registry Analysis (AOCRA) 2022 from India reports 2235 cardiac arrest which includes 1998 IHCA from 2017 to 2022, had 16.7% ROSC and 6.6% having good neurological outcome at discharge [7]. A systematic review which analyses 40 IHCA studies from 1985–2018 reports 13.4% one-year survival with wide variation across regions [8]. Studies based on CPR in Nepal are mostly done in academic institutions mainly on pediatric and neonatal populations, most often highlighting the performance of the trainees, unavailability of equipment, and lack of adherence to standard guidelines [9–11]. There is dearth of literature in low and middle income country particularly Nepal regarding the burden of the problem in and outside the hospital, and even if intervention is done in the hospital setting, standardization and the outcome of the patients are hardly measured. The study aims to highlight the prevalence, performance, and outcome of CPR in government hospitals of Nepal.
Methods
Study design
A mixed-method design study was done during the period of 2 months (June 15, 2021- August 15, 2021) prospectively. Quantitative part of the study included an observational study which was done using face to face interview using a questionnaire with one of the participants of the CPR. The ‘participant’ was defined as the healthcare personnel who took active participation during the time of CPR, either as chest compressor, airway manager, drug administrator, defibrillator, data collector or as the head of the resuscitation team. A phenomenological design was used to assess the qualitative part of the study using an in-depth interview of the resuscitation performer.
Settings
The government hospitals were sampled in two strata—central hospitals under the federal government, and provincial hospitals under the provincial government. Facilities were randomly chosen from the two strata of central and provincial hospitals from the list of hospitals from the website of the Ministry of Health and Population and after confirmation of the presence of critical care facility for post-resuscitation care. For the study purpose, two central hospitals, one inside and other outside the capital city Kathmandu was taken. Two provincial hospitals outside Kathmandu were taken as per the list of Government of Nepal. Two central hospitals of the Government of Nepal, National Academy of Medical Sciences, National Trauma Center, Kathmandu, Nepal (inside the capital) and Karnali Academy of Health Sciences, Jumla, Nepal (outside the capital) were selected randomly for the study. Two provincial hospitals Seti Provincial Hospital, Dhangadi and Lumbini Provincial Hospital, Butwal were selected.
Sample size and sampling
Registry-based data from the United Kingdom indicate a cardiac arrest prevalence of 1.6 per 1000 population per year [5]. Similarly, in the United States, the estimated annual incidence of cardiac arrest is 9–10 arrests per 1000 admissions. If we look at the prevalence of IHCA in an African hospital study, it is 2.3% [6]. Similarly, in a study done in India, the prevalence of IHCA is as high as 6.7% [12]. So, we took a value of around 5% as the estimated value of prevalence of cardiac arrest in our study. Taking the prevalence as 5% and the precision level as 5%, the minimum sample size was calculated as 73. Taking in consideration the non-response rate of 10%, a sample size of 80 was taken as final. Using two strata and considering that the major load of cases will be in the central hospitals than in provincial hospitals, 75% (total 60) of the data was collected from central hospitals and 25% of the data from the provincial hospitals (total 20). The cases were selected based on convenience. For qualitative part, exploratory sequential approach was done with in-depth interview taken from the selected participants. We planned to take maximum 25 interviews randomly from different institutes taking in account that 75% of the participant were from the central hospitals and 25% from the provincial hospitals. The numbers are based under assumptions that data saturation would take place at this point. However, we decided to stop with 15 interviews after a collective conclusion that all thematic heading has been repeatedly answered and it is less likely to lose some finding.
Data collection and analysis
Data was collected by questionnaire method by a trained data enumerator who is well-versed and trained in CPR from among the hospital staff involved in performing CPR. Data was collected from the one of the participants involved in CPR as early as possible and not exceeding 10 days. The questionnaire was adapted as per the algorithms of the American Heart Association(AHA) [13]. Data was entered in the central entry system prepared by the investigating team. Data collection was monitored by the supervisor of the study. Interviewer are also advised to follow the cardiac arrest event every day at the hospitals and make efforts not to miss any data. In-depth interview was done purposively with audio recording for qualitative data after taking consent. The interviews were transcribed by an independent person trained in CPR from Nepali to English.
For data analysis, prevalence of CPR in different strata of the hospital was calculated taking into consideration all inpatients who were admitted in the emergency, hospital wards and intensive care units irrespective of duration of admission as the denominator. Other variables of study include outcome of arrest victim after CPR, occurrence of cardiac arrest at different sites of the hospital (emergency, intensive care unit, medical wards), training level of health care provider, estimated time from recognition to start of the CPR, conduct of chest compression and airway management, initial rhythm, use of monitor during CPR and outcome of arrest (S1 Table). Data enumerators were oriented before the collection of data. The principal investigator and the co-investigators supervised issues related to data collection. Qualitative variables were identified and expressed as numbers and percentages. Numerical variables were presented as mean and standard deviation. SPSS version 22 software was used to analyze the data. All the video interviews were recorded after consent and transcribed by independent person trained in CPR. The transcribed document was entered and thematic analysis was done using Dedoose 8.0.42. version. Thematic analysis was done as per AHA 2020 guideline IHCA chain of survival which is presented as follows (Table 1) [13].
Ethical approval and consent
Ethical approval was obtained from the Nepal Health Research Council (NHRC) (Ethical Review Committee Approval No:14612021P). Health personnel who had actively participated in the CPR were taken in-depth interviews using pre-formed questionnaire. For the quantitative part, written informed consent was taken before the interview, maintaining confidentiality. For the qualitative part, verbal consent was again taken before the start of the audio interview and recorded. Identity of the participant were not entered in the data sheet and any identifier that indirectly identified the participant were also deleted at the time of data entry. All this process was approved by the Ethical board of NHRC and the local institutional review board of the selected site.
Results
Most of the arrest were 48.2 ± 17.1 (82–15) years of age with most interview of the healthcare provider conducted in 2.6 ± 2.4 (1–10) days (Table 2).
The prevalence of the CPR in hospital was 1.92% with most higher incidences in the central hospitals 5.25% (Table 3).
Most of the CPR were recognized and started within 1.9 ± 1.4 (1–10) minutes and conducted for 23.5 ± 15.0 (2–80) minutes (Table 6).
Asystole was the commonest rhythm observed. The second most frequent finding was difficulty interpreting rhythm. (Table 7).
Almost 11.25% (9) arrest have ROSC (Table 8) with most being transferred for post arrest care 10% (8).
Majority of the responses of the thematic analysis highlighted on the difficulties of early recognition and prevention, lack of clear-cut strategies for activation of emergency response system, poor performances and lack of feedback for chest compression, lack of provision for post cardiac arrest care and rehabilitation (Table 9).
Discussion
International Liaison Committee on Resuscitation (ILCOR) states that resuscitation in low resource setting must be calibrated and discussed to obtain consensus by experts from all settings [14]. Cardiac arrest observations are poorly practiced and reported in low-income countries and need to be improved before practice implementation [14]. Even tertiary care hospitals of low-income countries with intensive care services and emergency wards have a low rate of CPR performance, ROSC and 24-hour survival [6]. Lack of funding, ineffective CPR training, lack of infrastructure and resources, ineffective layman response has been cited as key factors for poor patient outcome in low- and middle-income countries [15]. It has been suggested that the usual protocol for CPR developed in middle and high income countries cannot be implemented real-time in low-income countries [15]. The African Federation for Emergency Medicine raises the issues of international guidelines not adequately addressing the local needs of low resource communities [16].
IHCA prevalence in our study is 1.92% with notable variation in central and provincial hospital with majority of events occurring in intensive care unit. A study done in Uganda in 2015 shows prevalence of 2.3% of IHCA with most cases occurring in critical care units and emergency and majority going unwitnessed [6]. In the United States, Medicare data for patients older than 65 documents the prevalence of cardiac arrest of 2.73 per 1000 population in hospital admissions from 1992–2005 [17]. There is evidence of regional variation from 2.33/1000 to 3.73/1000 hospital admission from the east side of the United States to the west which was partially explained by patient and hospital characteristics [18]. The high rate of prevalence in our context can be partly explained by rising burden of cardiovascular disease, lack of standard of care offered in high resource setting owing to a scarcity in financial, infrastructural and logistical resources and sufficiently qualified personnel [14, 19]. Almost 50% of the data in our study (Table 3) is from the trauma center, where there is likelihood of severe case admissions and high incidence of arrest, with peripheral hospital mostly catering all types of healthcare services which might possibly dilute the prevalence. Additionally, there is a tendency to refer serious cases to higher center which may partially explain the regional variation of prevalence in the study.
If we look at the rhythm at the time of arrest, the Indian online cardiac registry with 2121 cases shows asystole (67.7%) as the commonest rhythm, followed by PEA (25.6%), VT/VF (6.7%) [7]. In a study from Kenya, which is also a low-middle income country, 353 IHCA in different hospitals showed Non-shockable rhythms (Asystole: 47.6%, PEA: 38.2%, VT/VF: 5.4%, Unknown: 8.8%) for the majority of the cardiac arrests [20]. In our study, difficulty interpreting rhythm which is the second commonest finding (Table 7), may stem from multiple factors. These could include insufficient skills in rhythm recognition, malfunctioning or unavailable monitors, poor team dynamics and potential oversight by the interviewer due to multitasking during the event. It is also worth noting that majority of respondent in our study were untrained or partially trained, (Table 5) a finding in consistent with other study done in Nepal regarding CPR knowledge [21].
Our study shows 25% (20) of the patients had ROSC, out of whom 11.25% (9) patients were transferred for post-arrest care (Table 8). We did not have data on the 24-hour survival, and the number of patients discharged from the hospital. In Pakistan, a study done in the Emergency, out of 468 victims, 27.4% (128) had ROSC with 7.5% (35) survival to discharge.(26) In a small study done regarding IHCR in Uganda in 2015, 14 (7.4%) had ROSC, and only 3 (1.6%) had a 24-hour survival [6]. In another study done in 6 Kenyan hospital, ROSC occurred in 29.2% of patients and only 16 arrest (4.2%) were successfully discharged from the hospital [20]. In the Indian cardiac arrest registry, ROSC occurred in 355 (16.7%) patients, among whom 173 (8.2%) were alive and 14 (6.6%) has good neurological outcome [7]. In Thailand where facilities are well-equipped, it was interesting to see almost 62% cardiac arrest had a ROSC but survival to discharge was only 7% [22]. ROSC and patient improvement in neurological outcome is a collective effort of Chain of survival in AHA algorithm. In a Nigerian survey of 17 hospitals, which included most government hospitals that had the provision of intensive care services, it was found that only 20% hospitals had an appropriate cardiac arrest response team system, only 21% events were documented properly, and only 21% events were reviewed for educations and quality improvements. These are low-cost strategies for continuous quality improvements, which were ignored [23].
This study was done in a limited duration with efforts to include hospitals with the possibility of wide variations in service delivery. It is possible that interviewer might have missed some arrest event while following every day. Additionally, we stopped data collection upon reaching our desired sample which almost matched 2-month duration which might slightly underestimate prevalence. There are chances that interviewee might have missed important observations as he/she was busy doing one of the skills of the CPR. The annual hospital data, particularly of the peripheral hospital, might dilute CPR prevalence. Outside the hospital cardiac arrest which continued as IHCA and those occurring in the operation theatre were not recorded in our study which might underreport occurrences. A larger nationwide study done with hospitals of different tier’s delivering resuscitation services might give a clearer picture.
Conclusions
IHCA is prevalent across many tiers of Nepal’s government healthcare system. The most common CPR rhythm is asystole, with approximately one tenth having ROSC and transferred for post arrest care. During various stages of chain of survival, there is inadequate recognition of cardiac arrest, poor performance and feedback during CPR and inadequate post-resuscitation care and rehabilitation. Additionally, there are insufficiently skilled healthcare personnel and a team dedicated to performing CPR. To improve the conduct and outcome of IHCR, a comprehensive system approach is recommended.
Acknowledgments
We would like to acknowledge the staffs, healthcare providers and study site hospitals for providing data for the study. We would also like to thank Nepal Health Research Council for providing Provincial Health Research Grant 2021 for this study.
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