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Virtually every Code Blue responder knows the feeling of relief that comes with an IHCA patient achieving return of spontaneous circulation (ROSC). Unfortunately, most also know the disappointment of finding out during their next shift that the same patient either didn’t survive or will likely not recover neurologically. Many are left wondering what, if anything, they could have done to ensure a better result.

The truth is, many factors can impact outcomes following in-hospital cardiac arrest. And how clinicians and other first responders interpret those factors — and even the outcomes themselves — can make a big difference in how they choose and address quality improvement initiatives.

Keep reading for some enlightening data about long-term IHCA outcomes, which factors impact those outcomes, and how to optimize the factors that are within the hospital and code team’s control.

Beyond ROSC: Focusing On Long-Term Outcomes for In-Hospital Cardiac Arrest

Code Blue responders often (and understandably) prioritize ROSC over virtually any other outcome. After all, without ROSC, the coding patient doesn’t survive the initial cardiac arrest event. But it’s important for hospitals and code teams to look beyond this immediate goal, to get a broader picture of IHCA outcomes and how to improve them.

When resuscitation teams and committees meet to review case data, they should take into account a wider range of outcomes, spanning more time and considerations beyond survival. Depending on what information is regularly tracked for each patient, these could include:

  • Return of spontaneous circulation (ROSC)
  • Survival to hospital discharge
  • 30-day survival
  • 6-month survival
  • Neurological recovery and/or prognosis

If ROSC rates are relatively good but survival to discharge and/or neurological outcomes are not, this may indicate there are some aspects of care during or after the code that require deeper analysis and possible quality improvement initiatives.

Factors That Impact Long-Term Outcomes for In-Hospital Cardiac Arrest

The American Heart Association has long emphasized high-quality CPR and early defibrillation as the two most impactful interventions for achieving ROSC. But when it comes to long-term outcomes, are there other factors that should be taken into account? Or is adherence to these Advanced Cardiac Life Support (ACLS) best practices the most important consideration across the board?

Let’s look at the data:

  • A review of 86,748 adult in-hospital cardiac arrest cases from 507 participating hospitals analyzing survival of the event, survival to discharge, 24-hour survival, and favorable neurological outcome found that time of day and location of the patient within the hospital significantly impacted survival and neurological outcomes.1
  • In a large study out of Sweden including 18,069 adults receiving an ACLS response to their first cardiac arrest, 30-day survival was most impacted by time of day and type of rhythm. Having an arrest response during the daytime and having a ventricular tachycardia (VT) or ventricular fibrillation (VF) rhythm were associated with the best survival rates.2
  • A subsequent Swedish study found similar 30-day survival rates (around 30%) where time of day and ECG monitoring were associated with improved chances of survival.3
  • A large study reviewing cases of over 12,000 patients over a 9-year period analyzed the impact of high-quality CPR started within a minute of arrest, as well as defibrillation for VT/VF within 2 minutes of arrest. Patients with a shockable rhythm and early, high-quality CPR had a 66.1% 30-day survival rate, compared to only 46.5% where high-quality CPR and timely defibrillation were not achieved.4
  • Long-term neurological outcomes were also much improved when ACLS criteria for high-quality CPR and early defibrillation were met during arrest events.

Optimizing Factors Associated with Resuscitation Performance

While no one can control what time of day a patient goes into cardiac arrest, what department of the hospital they are in when they experience IHCA, or what type of rhythm they will encounter, there are clearly some critical factors within hospitals’ and clinicians’ purview.

Hospitals should take a close look at why time of day and location within the hospital are often such strong indicators of long-term prognosis:

  • If significantly more IHCA patients are experiencing poor long-term outcomes when their arrest occurs outside of peak hours, this may signal that the hospital needs more staffing at night or on weekends.
  • If outcomes tend to be worse in a specific department, perhaps a different staff distribution could better support those areas experiencing poorer IHCA outcomes.

For clinicians, the impact of ACLS best practices, including high-quality CPR and early defibrillation for VT/VF, on long-term term survival and neurological prognosis is undeniable. And one of the most effective ways to ensure staff are routinely carrying out those best practices is to institute regular in-situ mock codes:

  • Data shows that these simulated hospital emergency sessions can improve response times and efficiency, patient survival, and neurological outcomes.5-8
  • In fact, hospitals with active in-situ mock code programs report higher survival rates for in-hospital cardiac arrest than those who do not offer this type of training.9


Take the Next Step

Ready to see what an in-situ mock code program can do for your hospital? Read 5 Steps to Running a Successful Mock Code Blue Program next!


  1. Peberdy MA, Ornato JP, Larkin GL, et al. Survival From In-Hospital Cardiac Arrest During Nights and Weekends. JAMA. 2008;299(7):785-792. doi:10.1001/jama.299.7.785
  2. Hessulf, F., Herlitz, J., Rawshani, A., Aune, S., Israelsson, J., Södersved–Källestedt, M.-L., Nordberg, P., Lundgren, P., & Engdahl, J. (2020). Adherence to guidelines is associated with improved survival following in-hospital cardiac arrest. Resuscitation, 155, 13–21.
  3. Schluep, M., Hoeks, S., Blans, M., van den Bogaard, B., Koopman-van Gemert, A., Kuijs, C., Hukshorn, C., van der Meer, N., Knook, M., van Melsen, T., Peters, R., Perik, P., Simons, K., Spijkers, G., Vermeijden, W., Wils, E.-J., (Robert Jan) Stolker, R., & (Rik) Endeman, H. (2021). Long-term survival and health-related quality of life after in-hospital cardiac arrest. Resuscitation, 167, 297–306.
  4. Hessulf, F., Karlsson, T., Lundgren, P., Aune, S., Strömsöe, A., Södersved Källestedt, M.-L., Djärv, T., Herlitz, J., & Engdahl, J. (2018). Factors of importance to 30-day survival after in-hospital cardiac arrest in sweden – a population-based register study of more than 18,000 cases. International Journal of Cardiology, 255, 237–242.
  5. Herbers, M. D., & Heaser, J. A. (2016). Implementing an in situ mock code quality improvement program. American Journal of Critical Care, 25(5), 393–399.
  6. Ngo, D. Q., Vu, C., Nguyen, T., Sotolongo, P., Talati, M., Zahabi, N., & Platt, K. (2020). The effect of mock code blue simulations and dedicated advanced cardiac life support didactics on resident perceived competency. Cureus. Retrieved July 29, 2021, from
  7. American Heart Association Guidelines for CPR & ECC: 2020 Updates.
  8. Nallamothu, B. K., Guetterman, T. C., Harrod, M., Kellenberg, J. E., Lehrich, J. L., Kronick, S. L., Krein, S. L., Iwashyna, T. J., Saint, S., & Chan, P. S. (2018). How do resuscitation teams at top-performing hospitals for in-hospital cardiac arrest succeed? Circulation, 138(2), 154–163. 
  9. Josey, K., Smith, M. L., Kayani, A. S., Young, G., Kasperski, M. D., Farrer, P., Gerkin, R., Theodorou, A., & Raschke, R. A. (2018). Hospitals with more-active participation in conducting standardized in-situ mock codes have improved survival after in-hospital cardiopulmonary arrest. Resuscitation, 133, 47–52.
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