Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion

Jack Chen, Lixin Ou, Kenneth M Hillman, Arthas Flabouris, Rinaldo Bellomo, Stephanie J Hollis and Hassan Assareh
Med J Aust 2014; 201 (3): 167-170. || doi: 10.5694/mja14.00019


Objectives: To understand the changes in the population incidence of inhospital cardiopulmonary arrest (IHCA) and mortality associated with the introduction of rapid response systems (RRSs).

Design, setting and participants: Population-based study of 9 221 138 hospital admissions in 82 public acute hospitals in New South Wales, using data linked to a death registry, from 1 Jan 2002 to 31 Dec 2009.

Main outcome measures: Changes in IHCA, IHCA-related mortality, hospital mortality and proportion of IHCA patients surviving to hospital discharge.

Results: RRS uptake increased from 32% in 2002 to 74% in 2009. This increase was associated with a 52% decrease in IHCA rate, a 55% decrease in IHCA-related mortality rate, a 23% decrease in hospital mortality rate and a 15% increase in survival to discharge after an IHCA (all P < 0.01). The adjusted absolute reductions in IHCA-related mortality and hospital mortality were 1.49 (95% CI, 1.30–1.68) and 4.05 (95% CI, 3.17–4.76) patients per 1000 admissions, respectively. The decrease in IHCA incidence rate accounted for 95% of the reduction in IHCA-related mortality. In contrast, the increase in IHCA survival accounted for only 5% of the reduction in IHCA-related mortality.

Conclusions: During nearly a decade, as RRSs were progressively introduced, there was a coincidental reduction in IHCA, IHCA-related deaths and hospital mortality and an increased survival to hospital discharge after an IHCA. Reduced IHCA incidence, rather than improved postcardiac arrest survival, was the main contributor to the reduction in IHCA mortality.

Please login with your free MJA account to view this article in full

  • Jack Chen1
  • Lixin Ou1
  • Kenneth M Hillman1
  • Arthas Flabouris2,3
  • Rinaldo Bellomo4
  • Stephanie J Hollis1
  • Hassan Assareh1

  • 1 University of New South Wales, Sydney, NSW.
  • 2 Intensive Care, Royal Adelaide Hospital, Adelaide, SA.
  • 3 School of Medicine, University of Adelaide, Adelaide, SA.
  • 4 Austin Hospital, Melbourne, VIC.



Our study was supported by National Health and Medical Research Council project grants APP1009916 and APP1020660.

Competing interests:

No relevant disclosures.

  • 1. Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academies Press, 2000.
  • 2. Morrison LJ, Neumar RW, Zimmerman JL, 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.
  • 3. Kause J, Smith G, Prytherch D, et al. A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom -- the ACADEMIA study. Resuscitation 2004; 62: 275-282.
  • 4. Devita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006; 34: 2463-2478.
  • 5. Winters BD, Weaver SJ, Pfoh ER, et al. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med 2013; 158 (5 Pt 2): 417-425.
  • 6. Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Med J Aust 2003; 179: 283-287. <MJA full text>
  • 7. Buist MD, Moore GE, Bernard SA, et al. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ 2002; 324: 387-390.
  • 8. Chen J, Bellomo R, Flabouris A, et al. The relationship between early emergency team calls and serious adverse events. Crit Care Med 2009; 37: 148-153.
  • 9. Jones DA, Bagshaw SM, Barrett J, et al. The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study. Crit Care Med 2012; 40: 98-103.
  • 10. Chan PS, Jain R, Nallmothu BK, et al. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med 2010; 170: 18-26.
  • 11. Mullins RJ, Mann NC. Population-based research assessing the effectiveness of trauma systems. J Trauma 1999; 47 (3 Suppl): S59-S66.
  • 12. Cameron PA, Gabbe BJ, Cooper DJ, et al. A statewide system of trauma care in Victoria: effect on patient survival. Med J Aust 2008; 189: 546-550. <MJA full text>
  • 13. Greenland S. Model-based estimation of relative risks and other epidemiologic measures in studies of common outcomes and in case-control studies. Am J Epidemiol 2004; 160: 301-305.
  • 14. White H. Maximum likelihood estimation of misspecified models. Econometrica 1982; 50: 1-26. doi: 10.2307/1912004.
  • 15. Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005; 43: 1130-1139.
  • 16. Wennberg JE, Staiger DO, Sharp SM, et al. Observational intensity bias associated with illness adjustment: cross sectional analysis of insurance claims. BMJ 2013; 346: f549.
  • 17. Priestley G, Watson W, Rashidian A, et al. Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital. Intensive Care Med 2004; 30: 1398-1404.
  • 18. Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet 2005; 365: 2091-2097.
  • 19. Girotra S, Nallamothu BK, Spertus JA, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med 2012; 367: 1912-1920.
  • 20. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA 2005; 293: 2384-2390.
  • 21. Benning A, Dixon-Woods M, Nwulu U, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ 2011; 342: d199.
  • 22. Australian Institute of Health and Wellfare. Australian hospital statistics 2011-12. Canberra: AIHW, 2013. (AIHW Cat. No. HSE 134; Health Services Series 50.) (accessed May 2014).
  • 23. Lee KH, Angus DC, Abramson NS. Cardiopulmonary resuscitation: what cost to cheat death? Crit Care Med 1996; 24: 2046-2052.
  • 24. Nolan JP. Optimizing outcome after cardiac arrest. Curr Opin Crit Care 2011; 17: 520-526.
  • 25. Chen J, Flabouris A, Bellomo R, et al. The Medical Emergency Team System and not-for-resuscitation orders: results from the MERIT study. Resuscitation 2008; 79: 391-397.


remove_circle_outline Delete Author
add_circle_outline Add Author

Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Responses are now closed for this article.