Samuel A. Hofacker1; Matthew E. Dupre, PhD2,4; Kimberly Vellano, MS3; Bryan McNally, MD3; Myles Wolf, MD, MMSc2,5; Laura P. Svetkey, MD, MHS5; Patrick H. Pun, MD, MHS2,5
1Duke University School of Medicine, 2Duke Clinical Research Institute, 3Dept. of Emergency Medicine, Emory University, 4Dept. of Population Health Sciences, Duke University School of Medicine, 5Div. of Nephrology, Dept. of Medicine, Duke University School of Medicine
Sudden cardiac arrest is the leading cause of death among patients receiving maintenance hemodialysis.1 Despite guidelines recommending that dialysis staff undergo basic life support training and that all dialysis clinics have automated external defibrillators (AEDs) on site, rates of cardiopulmonary resuscitation (CPR) and AED use by dialysis staff are suboptimal.2 Patient race/ethnicity has been linked to lower rates of bystander CPR in cardiac arrests occurring in non-healthcare settings.3 We examined the likelihood of receiving CPR and AED application by staff within dialysis clinics, based on patient race/ethnicity.
We analyzed data prospectively collected in the Cardiac Arrest Registry to Enhance Survival across the U.S. from 2013-2017 and linkage to the Centers for Medicare & Medicaid Services dialysis facility database to identify cardiac arrest events within outpatient dialysis clinics. We used multivariable logistic regression models to examine relationships between patient race and dialysis staff-initiated CPR and AED application, and the effect of staff resuscitation efforts on survival outcomes.
Among 1,568 cardiac arrests occurring in 809 hemodialysis clinics, 31.3% of patients were White, 32.9% Black, 10.7% Hispanic/Latinx, and 2.7% Asian. Overall, 88.0% received CPR initiated by dialysis staff, but rates differed by race: 91% in white patients, 85% in black patients, and 77% in Asian patients (p=0.005). After adjusting for differences in patient and clinic characteristics, black (OR=0.41, 95% CI 0.25-0.68) and Asian patients (OR=0.28, 95% CI 0.12-0.65) were significantly less likely than white patients to receive CPR initiated by dialysis staff. An AED was applied by dialysis staff prior to the arrival of emergency personnel in 62% of patients. After adjustment for differences in patient and clinic characteristics, there was no relationship between patient race and AED application by dialysis staff. Staff-initiated CPR was associated with improved patient survival (OR=1.58, 95% CI 1.03-2.38), and the survival benefit did not differ by patient race.
Black and Asian patients are significantly less likely than white patients to receive CPR from dialysis staff, an intervention that improves survival outcomes. Further understanding of resuscitation practices in dialysis clinics and increased awareness of this racial disparity are necessary to improve resuscitation practices.
1USRDS Annual Data Report. Atlas of End-Stage Renal Disease in the United States. 2018.
2Pun PH, Dupre ME, Starks MA et al. Outcomes for Hemodialysis Patients Given
Cardiopulmonary Resuscitation for Cardiac Arrest at Outpatient Dialysis Clinics. JASN. 2019; 30(3):461-470.
3Benson PC, Eckstein M, McClung CD, Henderson SO. Racial/ethnic differences in bystander CPR in Los Angeles, California. Ethn Dis. 2009;19(4):401-406.
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