Circulation: Cardiovascular Quality and Outcomes

ORIGINAL ARTICLE

Annual Incidence of Adult and Pediatric

In-Hospital Cardiac Arrest in the United
States

BACKGROUND: Previous incidence estimates may no longer reflect the Mathias J. Holmberg,
current public health burden of cardiac arrest in hospitalized adult and MD, MPH
pediatric patients across the United States. The aim of this study was to Catherine E. Ross, MD
estimate the contemporary annual incidence of in-hospital cardiac arrest Garrett M. Fitzmaurice, ScD
in adults and children across the United States and to describe trends in Paul S. Chan, MD, MSc
incidence between 2008 and 2017. Jordan Duval-Arnould,
MPH, DrPH
METHODS AND RESULTS: Using the Get With The Guidelines– Anne V. Grossestreuer,
Resuscitation registry, we developed a negative binomial regression PhD
model to estimate the incidence of index pulseless in-hospital cardiac Tuyen Yankama, MPH
arrest based on hospital-level characteristics. The model was used to Michael W. Donnino, MD
predict the number of in-hospital cardiac arrests in all US hospitals, Lars W. Andersen, MD,
using data from the American Hospital Association Annual Survey. MPH, PhD, DMSc
Downloaded from http://ahajournals.org by on July 19, 2019

for the American Heart

We performed separate analyses for adult (≥18 years) and pediatric
Association’s Get With
(<18 years) cardiac arrests. Additional analyses were performed for
The Guidelines–Resusci-
recurrent cardiac arrests and pediatric patients requiring cardiopulmonary tation Investigators*
resuscitation for poor perfusion (nonpulseless events). The average
annual incidence of in-hospital cardiac arrest in the United States was
estimated at 292 000 (95% prediction interval, 217 600–503 500) adult
and 15 200 pediatric cases, of which 7100 (95% prediction interval,
4400–9900) cases were pulseless cardiac arrests and 8100 (95%
prediction interval, 4700–11 500) cases were nonpulseless events. The
rate of adult cardiac arrests increased over time, while pediatric events
remained more stable. When including both index and recurrent in-
hospital cardiac arrests, the average annual incidence was estimated at
357 900 (95% prediction interval, 247 100–598 400) adult and 19 900
pediatric cases, of which 8300 (95% prediction interval, 4900–11 200)
cases were pulseless cardiac arrests and 11 600 (95% prediction interval,
6400–16 700) cases were nonpulseless events.
CONCLUSIONS: There are ≈292 000 adult in-hospital cardiac arrests and
15 200 pediatric in-hospital events in the United States each year. This *A list of all American Heart Association’s
study provides contemporary estimates of the public health burden of Get With The Guidelines-Resuscitation In-
vestigators is given in the Appendix.
cardiac arrest among hospitalized patients.
Key Words: epidemiology ◼ heart
arrest ◼ hospitals ◼ incidence

© 2019 American Heart Association, Inc.

https://www.ahajournals.org/journal/
circoutcomes

Circ Cardiovasc Qual Outcomes. 2019;12:e005580. DOI: 10.1161/CIRCOUTCOMES.119.005580 July 2019 1

 Holmberg et al; Incidence of In-Hospital Cardiac Arrest in the United States
WHAT IS KNOWN
• Previous studies have reported a national inci-
dence of 211 000 adult and 6000 pediatric pulse-
less in-hospital cardiac arrests across the United
States.
• These previous incidence estimates may no longer
reflect the current public health burden of cardiac
arrest in the United States.
WHAT THE STUDY ADDS
• We estimate that there are ≈292 000 adult in-hos-
pital cardiac arrests and 15 200 pediatric in-hospi-
tal events requiring cardiopulmonary resuscitation
in the United States each year.
• Compared with previous reports, the public health
burden of adult and pediatric pulseless in-hospital
cardiac arrest is ≈38% and 18% greater than pre-
viously estimated.
• The incidence of adult in-hospital cardiac arrests
increased between 2008 and 2017, while pediat-
ric events have remained more stable.
C
urrent national incidence estimates of adult in-
hospital cardiac arrest in the United States are
based on data from more than a decade ago.1
The most recent study used data from a prospective
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cardiac arrest registry to extrapolate the incidence of
in-hospital cardiac arrest to the total population of hos-
pitalized patients in the United States.2 The authors in-
cluded data from 2003 to 2007 and concluded that in-
hospital cardiac arrest occurs in ≈211 000 adult patients
in the United States each year. To our knowledge, there
are no available contemporary incidence estimates, and
these findings may no longer reflect the current inci-
dence of adult in-hospital cardiac arrest.
Incidence estimates of pediatric in-hospital cardiac
arrest in the United States are more obscure, as the
only nationwide estimate was calculated from several
separate data sources, all of which were single-center
studies using data before 2008.3 The estimate was pub-
lished in the 2013 American Heart Association consen-
sus statement concluding that in-hospital cardiac arrest
occurs in ≈6000 hospitalized children each year.4 How-
ever, more rigorous methods using the most contempo-
rary data are required to estimate the current incidence
of pediatric in-hospital cardiac arrest.
Understanding the contemporary public health
burden of in-hospital cardiac arrest is important for
informing healthcare policies, research priorities, and
tracking efforts to reduce events. In this study, we
aimed to estimate the annual incidence of in-hospital
cardiac arrest in adults and children across the United
States and to describe trends in incidence between
2008 and 2017.
Circ Cardiovasc Qual Outcomes. 2019;12:e005580. DOI: 10.1161/CIRCOUTCOMES.119.005580
METHODS
Study Design, Data Source, and Study
Population
We analyzed prospectively collected data from the Get With
The Guidelines–Resuscitation (GWTG-R) registry. The GWTG-R
registry is a voluntary, prospective, quality-improvement regis-
try of in-hospital cardiac arrest in the United States, sponsored
by the American Heart Association. Certified personnel at each
participating hospital collect data on all in-hospital cardiac arrest
patients without a do-not-resuscitate order. Cardiac arrest is
defined as the loss of a palpable central pulse or the presence
of a pulse with poor perfusion (pediatric patients only) requiring
chest compressions, defibrillation or both, with a hospital-wide
or unit-based emergency response by acute care personnel.
The design, data collection, and validity of the registry have
been described in detail elsewhere.2,5,6 IQVIA is the data collec-
tion coordination center for the American Heart Association/
American Stroke Association Get With The Guidelines pro-
grams. All participating hospitals are required to comply with
local regulatory guidelines. The Institutional Review Board at
Beth Israel Deaconess Medical Center (Boston, MA) has deter-
mined that research involving the GWTG-R registry does not
meet the federal definition of human subject research.
Hospital-level data were obtained from the 2010 and
2013 American Hospital Association Annual Survey.7 Hospitals
in the United States are registered by the American Hospital
Association if the institution is listed as a hospital by the Joint
Commission on Accreditation of Healthcare Organizations
or is certified as a provider of acute services under Title 18
of the Social Security Act. Hospitals not meeting these cri-
teria may be registered as a hospital by many alternative
requirements.8 The response rate for the American Hospital
Association Annual Survey averages ≈75%. Incomplete data
for selected characteristics of hospitals not responding or par-
tially responding to the Annual Survey are imputed using pre-
vious records.9
Patients in the GWTG-R registry were linked to hospitals in
the American Hospital Association data set by the American
Heart Association data management vendor. Because the
GWTG-R registry extends to 2017 and the American Hospital
Association data set was based on data from 2010 to 2013,
there is a small discrepancy in the number of patients and hos-
pitals which can be matched (ie, some hospitals have merged,
closed, or incomplete data).
For the primary analysis, we included adult (≥18 years of
age) and pediatric (<18 years of age) patients with an initial
or subsequent pulseless index cardiac arrest from January 1,
2008, to December 31, 2017, within the GWTG-R registry.
Patients at hospitals in the GWTG-R registry that could not
be linked to the American Hospital Association data set were
excluded.
Hospitals only seeing adult patients (100% adult beds)
were excluded from the pediatric analysis, and hospitals only
seeing pediatric patients (100% pediatric beds) were excluded
from the adult analysis, based on the variable fraction of adult
beds per hospital. Missing values for the fraction of adult beds
were imputed before exclusion of hospitals (see Statistical
Analysis). Hospitals in the American Hospital Association data
set with missing data for total number of hospital beds were
also excluded.
July 2019 2
 Holmberg et al; Incidence of In-Hospital Cardiac Arrest in the United States

The Strengthening the Reporting of Observational Studies Table 1.  Characteristics of Hospitals Providing Care to Adult Patients
in Epidemiology (STROBE) checklist is provided in the Data GWTG-R Non-GWTG-R
Supplement.10 Hospitals Hospitals
(n=398) (n=5887)

Statistical Analysis—Overview Adult hospital beds

For the primary analysis, we estimated the adult and pediat-  0–100 32 (8) 3387 (58)
ric incidence of pulseless in-hospital cardiac arrests separately.  100–199 80 (20) 1186 (20)
For each analysis, we developed regression models using data  200–249 32 (8) 345 (6)
from GWTG-R participating hospitals with the yearly hospital-
 250–299 41 (10) 264 (4)
level incidence as the dependent variable and hospital-level
characteristics as the independent variables. Coefficients from  300–349 40 (10) 166 (3)
the regression models were applied to the American Hospital  350–499 75 (19) 304 (5)
Association data set, which contains hospital-level data from  >499 98 (25) 235 (4)
the entire United States, to estimate annual national incidences.
Geographic region
Two additional preplanned analyses were performed. First,
we included both index and recurrent events to estimate the  North-East 73 (18) 743 (13)
overall burden of in-hospital cardiac arrest. Second, we cal-  South-East 104 (26) 908 (15)
culated estimates for pediatric patients requiring cardiopul-  North-Central 81 (20) 1629 (28)
monary resuscitation for poor perfusion (nonpulseless event),
 South-Central 63 (16) 1522 (26)
only including patients who maintained a pulse throughout
the entire sequence. As a post hoc analysis, we repeated the  West 77 (19) 1085 (18)
primary analysis to obtain adult incidence estimates after Geographic area
adding the number of hospital admissions to the regression  Urban 360 (90) 3652 (62)
model. This variable included both adult and pediatric admis-
 Rural 38 (10) 2235 (38)
sions and was, therefore, not used for the primary analysis.
SAS version 9.4 (SAS Institute, Cary, NC) was used for all Ownership type
analyses.  Government/military 64 (16) 1432 (24)

Incidence in GWTG-R Hospitals  Nonprofit 275 (69) 2867 (49)

We calculated the incidence of index in-hospital cardiac arrest  Private 59 (15) 1588 (27)
in GWTG-R participating hospitals (ie, the number of in-hos-
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Teaching hospital
pital cardiac arrests per hospital) per year from 2008 to 2017
 Nonteaching 173 (43) 3615 (78)
yielding one estimate per hospital per year of GWTG-R par-
ticipation. To ensure that hospitals entered data throughout  Minor 121 (30) 996 (17)
the entire year, we only included hospital-level data for those  Major 104 (26) 276 (5)
years with ≥1 reported event per quarter for the adult analy- Emergency department visits
sis and ≥1 reported event per year for the pediatric analy-
 0–10  000 11 (3) 3011 (51)
sis, given the lower incidence of the latter. We assumed that
acute care hospitals were unlikely to encounter <1 cardiac  10  001–50  000 175 (44) 2174 (37)
arrest over these time-periods.  50  001–100  000 166 (42) 559 (10)
 >100  000 46 (12) 143 (2)
Prediction Model Development
We developed 2 separate prediction models (pediatric and GWTG-R indicates Get With The Guidelines–Resuscitation.
adult) using the annual number of in-hospital cardiac arrests
per hospital as the dependent variable (ie, outcome) and (linear trend). To account for multiple observations within the
hospital-level data from GWTG-R participating hospitals as same hospitals over time (one incidence per year), we fit the
the independent variables (ie, predictors). Variables used negative binomial regressions using generalized estimation
for the analyses are provided in Tables  1 and 2. Based on equations with robust standard errors to account for any mis-
the distribution of in-hospital cardiac arrest (Figures I and specification of the correlation among the repeated measures
II in the Data Supplement), we used a multivariable regres- over time.11 An autoregressive variance-covariance structure
sion model with a negative binomial distribution to assess was used for the adult analysis, and an independent variance-
whether hospital-level characteristics were associated with covariance structure was used for the pediatric analysis to
the number of in-hospital cardiac arrests per hospital per year ensure convergence.
within the GWTG-R data set. Variables associated with the
number of events at a P<0.20 in unadjusted analyses were Application to the American Hospital Association
subsequently included in a multivariable model. Backwards Data Set
selection was then performed by sequentially eliminating vari- The American Hospital Association data set had complete
ables until only those significant at a P<0.05 remained. Year data on hospital-level characteristics for 5999 (95%) hospi-
was included in the model as a categorical variable irrespec- tals before imputation in the adult analysis and 5213 (77%)
tive of statistical significance. Additional post hoc analyses hospitals in the pediatric analysis (Tables I and II in the Data
were also performed including year as a continuous variable Supplement). Missing data on hospital-level characteristics

Circ Cardiovasc Qual Outcomes. 2019;12:e005580. DOI: 10.1161/CIRCOUTCOMES.119.005580 July 2019 3

 Holmberg et al; Incidence of In-Hospital Cardiac Arrest in the United States
Figure 1. Annual trends in the incidence of adult in-hospital cardiac
arrest in the United States.
The average number of index cardiac arrests occurring in hospitalized adult
patients between 2008 and 2017 was estimated at 292 000 (95% prediction
interval, 217 600–503 500) cases per year. There was an increase in cardiac
arrests over time (incidence rate ratio, 1.03; 95% CI, 1.02–1.03). Numerical
estimates are provided in Table IV in the Data Supplement.
were imputed under the assumption that data were miss-
ing at random using the fully conditional specification
method.12 A single imputed data set was created (see the
Data Supplement). The developed negative binomial regres-
sion models (see Prediction Model Development) were
applied to the imputed American Hospital Association data
set to estimate the annual national incidence of in-hospital
cardiac arrest in the United States. Predicted estimates were
obtained for all non-GWTG-R participating hospitals and
combined with the observed estimates from GWTG-R par-
ticipating hospitals. To obtain 95% prediction intervals,13 we
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performed cluster bootstrapping, randomly sampling data on
hospitals with replacements (n=1000 bootstrap samples). The
predicted estimates from the bootstrapping of the number of
in-hospital cardiac arrests per hospital per year accounted for
sampling error from the prediction models (estimation uncer-
tainty) and the fundamental variability of the cardiac arrest
counts (negative binomial dispersion). The 95% prediction
intervals for the annual national incidence estimates were
obtained using the 2.5 and 97.5 percentiles of the bootstrap
distribution of the estimates.
RESULTS
Adult In-Hospital Cardiac Arrest Incidence
A total of 6285 adult hospitals were included from
the American Hospital Association database, of which
398 hospitals were linked to the GWTG-R registry
(Table 1; Figure III in the Data Supplement). There were
167 013 cardiac arrests registered in the GWTG-R reg-
istry between 2008 and 2017 (Figure IV in the Data
Supplement), with a median of 76 (quartiles: 39 and
124) cases per hospital per year. Out of the 6 hospital
characteristics available for the analysis, 4 remained in
the final prediction model, including number of hos-
pital beds, emergency department visits, geographic
location, and geographic area (Table III in the Data
Supplement).
Circ Cardiovasc Qual Outcomes. 2019;12:e005580. DOI: 10.1161/CIRCOUTCOMES.119.005580
The average incidence across all hospitals in the
United States between 2008 and 2017 was estimated
at 292 000 (95% prediction interval, 217 600–503 500)
cases per year (Figure  1; Table IV in the Data Supple-
ment). The results were similar when adding the num-
ber of admissions to the model in the post hoc analysis,
with an estimated average incidence of 309 000 (95%
prediction interval, 210 000–586 700) cases. There was
an increase in adult in-hospital cardiac arrests over time,
with an estimated incidence of 268 200 (95% predic-
tion interval, 193  700–440  300) cases in 2008 and
328 700 (95% prediction interval, 248 100–583 900)
cases in 2017 (P<0.001). There was also an increase
in cardiac arrests over time when considering year as
a continuous variable (incidence rate ratio, 1.03; 95%
CI, 1.02–1.04; P<0.001). When including both index
and recurrent events, the average annual incidence
between 2008 and 2017 was estimated at 357 900
(95% prediction interval, 247 100–598 400) cases (Fig-
ure V and Tables V and VI in the Data Supplement).
Pediatric In-Hospital Event Incidence
A total of 2255 pediatric hospitals were included from
the American Hospital Association database, of which
212 hospitals with pulseless cardiac arrests and 158
hospitals with nonpulseless events were linked to the
GWTG-R registry (Table 2; Figure VI in the Data Supple-
ment). There were 6004 pulseless cardiac arrests and
5022 nonpulseless events registered in the GWTG reg-
istry between 2008 and 2017 (Figure VII in the Data
Supplement), with a median of 2 (quartiles: 1 and 8)
pulseless cardiac arrests and 4 (quartiles: 1 and 11) non-
pulseless events per hospital per year. Out of the 7 hos-
pital characteristics available for the analyses, 2 (num-
ber of hospital beds and teaching status) remained in
the model on pulseless cardiac arrests and 4 (number
of hospital beds, teaching status, emergency depart-
ment visits, and ownership type) remained in the model
on nonpulseless events (Tables VII and VIII in the Data
Supplement).
The average national pulseless in-hospital cardiac
arrest incidence was estimated at 7100 (95% predic-
tion interval, 4400–9900) cases per year (Figure 2; Table
IX in the Data Supplement). There was no clear change
in incidence over time (incidence rate ratio, 0.97; 95%
CI, 0.94–1.00; P=0.08), with an estimated incidence of
7900 (95% prediction interval, 4800–11 000) cases in
2008 and 6900 (95% prediction interval, 4300–9700)
cases in 2017. When including both index and recur-
rent pulseless cardiac arrests, the average annual inci-
dence was estimated at 8300 (95% prediction interval,
4900–11 200) cases (Figure VIII and Tables X and XI in
the Data Supplement).
The average national nonpulseless event incidence
was estimated at 8100 (95% prediction interval, 4700–
July 2019 4
 Holmberg et al; Incidence of In-Hospital Cardiac Arrest in the United States

Table 2.  Characteristics of Hospitals Providing Care to Pediatric

Patients

Pulseless Cardiac
Arrests Nonpulseless Events
Non- Non-
GWTG-R GWTG-R GWTG-R GWTG-R
Hospitals Hospitals Hospitals Hospitals
(n=212) (n=2043) (n=158) (n=2097)
Pediatric hospital beds
 None* 32 (15) 357 (17) 23 (15) 366 (17)
 1–10 44 (21) 928 (45) 25 (16) 947 (45)
 2–25 65 (31) 498 (24) 46 (29) 517 (25)
Figure 2. Annual trends in the incidence of pediatric pulseless in-
 26–50 31 (15) 162 (8) 25 (16) 168 (8)
hospital cardiac arrest in the United States.
 >50 40 (19) 98 (5) 39 (25) 99 (5) The average number of index pulseless cardiac arrests occurring in hospital-
ized pediatric patients between 2008 and 2017 was estimated at 7100 (95%
Pediatric ICU beds
prediction interval, 4400–9900) cases per year. There was no clear change in
 None* 112 (53) 1717 (84) 71 (45) 1758 (84) incidences over time (incidence rate ratio, 0.97; 95% CI, 0.94–1.00), P=0.08).
Numerical estimates are provided in Table XI in the Data Supplement.
 1–10 40 (19) 184 (9) 30 (19) 194 (9)
 >10 60 (28) 142 (7) 57 (36) 145 (7) When including both index and recurrent nonpulseless
Geographic region events, the average annual incidence was estimated at
 North-East 32 (15) 376 (18) 24 (15) 384 (18) 11 600 (95% prediction interval, 6400–16 700) cases
 South-East 59 (28) 343 (17) 45 (28) 357 (17) (Figure IX and Tables XIII and XIV in the Data Supple-
 North-Central 49 (23) 517 (25) 40 (19) 536 (26)
ment).
In aggregate, the national pediatric in-hospital event
 South-Central 38 (18) 422 (21) 28 (18) 432 (21)
incidence was calculated at 15 200 cases per year.
 West 34 (16) 385 (19) 31 (20) 388 (19)
When considering both index and recurrent events, the
Geographic area aggregate annual incidence was calculated at 19 900
 Urban 196 (92) 1509 (74) 145 (92) 1560 (74) cases.
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 Rural 16 (8) 534 (26) 13 (8) 537 (26)

Ownership type
DISCUSSION
 Government/ 30 (14) 352 (17) 23 (15) 359 (17)
military We used a large, multicenter, resuscitation registry to
 Nonprofit 158 (75) 1317 (64) 121 (77) 1354 (65) derive the contemporary incidence of in-hospital car-
diac arrest occurring annually in the United States. The
 Private 24 (11) 374 (18) 14 (9) 384 (18)
adult in-hospital cardiac arrest incidence was estimated
Teaching hospital
at 292 000 cases per year, whereas the incidence of
 Nonteaching 66 (31) 1263 (62) 37 (23) 1292 (62) pediatric in-hospital events was estimated at 15 200
 Minor 70 (33) 564 (28) 59 (37) 575 (27) cases per year, of which 7100 cases were pulseless car-
 Major 76 (36) 216 (11) 62 (39) 230 (11)
Emergency department visits
 0–10  000 4 (2) 278 (14) 2 (1) 280 (13)
 10  001–50  000 64 (30) 1089 (53) 38 (24) 1115 (53)
 50  001–100  000 105 (50) 531 (26) 87 (55) 549 (26)
 >100  000 39 (18) 145 (7) 31 (20) 153 (7)

GWTG-R indicates Get With The Guidelines–Resuscitation; and ICU,

intensive care unit.
*Including hospitals with pediatric events in the Emergency Department,
events where the patient was hospitalized in an adult bed, and hospitals with
designated neonatal beds.

11 500) cases per year (Figure 3; Table XII in the Data
Supplement). There was again no clear difference in
incidence over time (incidence rate ratio, 1.00; 95% CI,
0.97–1.04; P=0.09), with an estimated 7400 (95% pre-
diction interval, 4100–10 900) cases in 2008 and 8400
(95% prediction interval, 5000–11 700) cases in 2017.
Figure 3. Annual trends in the incidence of pediatric nonpulseless
events in the United States.
The average number of index nonpulseless events requiring cardiopulmonary
resuscitation in hospitalized pediatric patients between 2008 and 2017 was
estimated at 8100 (95% prediction interval, 4700–11 500) cases per year.
There was no clear difference in incidences over time (incidence rate ratio,
1.00; 95% CI, 0.97–1.04); P=0.09). Numerical estimates are provided in Table
XII in the Data Supplement.

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 Holmberg et al; Incidence of In-Hospital Cardiac Arrest in the United States
diac arrests and 8100 cases were nonpulseless events,
respectively. When predicting the number of index and
recurrent events, we estimated an incidence of 357 900
adult in-hospital cardiac arrests and 19 900 pediatric in-
hospital events requiring cardiopulmonary resuscitation
annually, of which 8300 cases were pulseless cardiac
arrests, and 11 600 cases were nonpulseless events.
Our findings indicate that the public health bur-
den of adult and pediatric in-hospital cardiac arrest
is ≈38% and 18% greater than previously reported,
respectively.2,4 Moreover, the results suggest that in-
hospital cardiac arrest occurs with nearly the same
frequency as out-of-hospital cardiac arrest. When com-
bining these findings with the previously reported out-
of-hospital cardiac arrest incidence of 347 300 adult
and 7000 pediatric cases,1 the total burden of cardiac
arrest reaches ≈640 000 adult and 22 000 pediatric
index cases annually in the United States. The current
data further demonstrate that the annual incidence of
professionally treated adult in-hospital cardiac arrests
is substantially higher compared with professionally
treated out-of-hospital cardiac arrests, with a reported
180 200 adult EMS-treated cardiac arrests in the out-
of-hospital setting.1 This information may have impor-
tant implications for hospital-based Basic Life Support
and Advanced Cardiac Life Support training programs,
which have traditionally focused on out-of-hospital car-
diac arrests.
With a reported survival rate of 25.8% and 37.9%
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for adult and pediatric in-hospital cardiac arrests in
20161 and 53.0% for pediatric nonpulseless events
between 2000 and 2008,14 our estimates can be trans-
lated to ≈216 700 adult deaths from in-hospital car-
diac arrest and 8200 pediatric deaths from in-hospital
events in the United States each year, corresponding
to 4400 pediatric deaths from in-hospital cardiac arrest
and 3800 pediatric deaths from nonpulseless events.
Additionally, based on the reported 30.2 million adults
and 5.6 million pediatric hospital stays in the United
States during 2015,15 the estimated in-hospital event
incidence can be extrapolated to 9.7 adult cardiac
arrests and 2.7 pediatric events per 1000 hospitaliza-
tions.
Few previous studies have estimated the national
incidence of adult in-hospital cardiac arrest in the Unit-
ed States. The most recent estimate was published by
Merchant et al2 in 2011 who leveraged the GWTG-R
registry and the American Hospital Association data-
base using a similar approach as the current study.2 The
authors estimated an average incidence between 2003
and 2007 of ≈211 000 adult cases per year, compared
with 292 000 cases in our study. There may be multiple
explanations for the discrepant findings. First, while
Merchant et al2 included the volume of beds and inten-
sive care unit beds as model predictors, it is unclear
whether these variables were restricted to adult, pedi-
Circ Cardiovasc Qual Outcomes. 2019;12:e005580. DOI: 10.1161/CIRCOUTCOMES.119.005580
atric, or all beds. Second, we and others2 have found
an increase in the number of cardiac arrests over
time, with an estimated increase of 23% from 2008
to 2017 in our study. Third, the number of hospitals
in the United States and hospital-level characteristics
may have changed since the publication of the previous
incidence estimates. Merchant et al2 calculated the inci-
dence based on 433 GWTG-R and 5445 non-GWTG-R
hospitals, compared with 398 GWTG-R and 5887 non-
GWTG-R hospitals in our data set. These differences are
partly because of different exclusion criteria, and the
former study may have included hospitals not report-
ing cardiac arrest cases to the GWTG registry. Last, the
availability of some covariates used for the prediction
model differed from the previous study, although most
variables were overlapping.
Incidence estimates of pediatric pulseless in-hospital
cardiac arrest are more scarce, and the current national
estimate is based on data from smaller observational
studies.4 In a systematic review and meta-analysis
from 2010, the number of rapid-response team acti-
vations for in-hospital cardiac arrest was calculated
from 5 single-center studies (3.26 activations per 1000
admissions),3 which after extrapolation by the nation-
al number of pediatric hospital admissions yielded
≈6000 pediatric pulseless cardiac arrests per year.4 In
comparison, our estimated average incidence of 7100
cases suggests that the burden of pediatric pulseless
in-hospital cardiac arrest is 18% greater than that previ-
ously estimated. While we found no indication that the
number of pediatric events has increased over time, our
estimates are based on a larger database and provide
the most robust estimate of pediatric in-hospital car-
diac arrest cases in the United States to date. Addition-
ally, a study from 2012 used the Healthcare Cost and
Utilization Project Kids Inpatient Database to estimate
the total (pulseless and nonpulseless) incidence of pedi-
atric events requiring cardiopulmonary resuscitation in
the United States, including both index and recurrent
events.16 The authors reported an annual incidence of
5800 (95% CI, 5259–6355) cases which is considerably
lower compared with the reported 19 900 cases in our
study, although administrative data are inherently lim-
ited by the current coding system and the absence of
detailed clinical information.17
No previous study has specifically estimated the
national incidence of pediatric nonpulseless events,
although an earlier report from the GWTG-R registry
suggests that about 35% of all children requiring car-
diopulmonary resuscitation never become pulseless.14
Since children may present with bradycardia and poor
perfusion before deteriorating into pulseless cardiac
arrest, the Pediatric Advanced Life Support guidelines
recommend the provision of chest compressions and
ventilation to these patients.18 In comparison to the
previous report, we estimated an average incidence
July 2019 6
 Holmberg et al; Incidence of In-Hospital Cardiac Arrest in the United States
of 8100 nonpulseless events, corresponding to about
53% of all pediatric events. The higher ratio of non-
pulseless events may be explained by the weighting of
our estimates to all US hospitals. Furthermore, hospitals
reporting nonpulseless events were fewer and reported
a greater number of cases per hospital per year, com-
pared with hospitals reporting pediatric pulseless car-
diac arrests (Figure II in the Data Supplement).
Our study should be interpreted in the context of
some limitations. First, we excluded hospitals which
could not be linked to the GWTG-R data set, and the
overall number of GWTG-R hospitals providing data
for the prediction model was relatively small (Figures III
and VI in the Data Supplement). Mandatory reporting
requirements for in-hospital cardiac arrest and higher
hospital participation in the GWTG-R registry may allow
for more precise incidence estimates. Second, we were
limited by the time of matching between the GWTG-
R registry and the 2010 and 2013 American Hospital
Association database. Hospital-level characteristics
were, therefore, assumed to be static over time. Third,
the prediction model was dependent on the number of
cardiac arrest cases registered in the GWTG-R registry. It
is possible that hospitals could have underreported the
number of cardiac arrests and not entered consecutive
cases into the registry, which could lead to an underes-
timation of the true incidence when the GWTG-R data
were extrapolated to all US hospitals. In addition, cases
not receiving a hospital-wide or unit-based emergency
Downloaded from http://ahajournals.org by on July 19, 2019
response (eg, cardiac arrests in the catheterization labo-
ratory and operating room) and patients declared dead
without provision of cardiopulmonary resuscitation are
not included in the registry. The estimated incidences
in this study should, therefore, be considered conserva-
tive. Fourth, the prediction model was limited by the
variables available in the American Hospital Association
data set, and there is a possibility that more granular
hospital-level characteristics (including patient case-
mix) could have improved the validity and precision of
our estimates. Last, we assumed that the relationship
between the incidence in GWTG-R participating hospi-
tals was transferable to non-GWTG-R participating hos-
pitals, although we were not able to assess the validity
of this assumption.
CONCLUSIONS
Our analyses indicate that there are ≈292 000 adult in-
hospital cardiac arrests and 15 200 pediatric in-hospital
events requiring cardiopulmonary resuscitation in the
United States each year. The incidence of adult in-
hospital cardiac arrests has increased over time, while
pediatric events remained more stable. These estimates
provide contemporary annual estimates of the public
health burden from in-hospital cardiac arrest in the
United States.
Circ Cardiovasc Qual Outcomes. 2019;12:e005580. DOI: 10.1161/CIRCOUTCOMES.119.005580
ARTICLE INFORMATION
Received February 6, 2019; accepted May 13, 2019.
Guest Editor for this article was Karin H. Humphries, DSc.
The Data Supplement is available at https://www.ahajournals.org/doi/
suppl/10.1161/CIRCOUTCOMES.119.005580.
Correspondence
Lars W. Andersen, MD, MPH, PhD, DMSc, Research Center for Emergency
Medicine, Department of Clinical Medicine, Aarhus University Hospital, Email
lwandersen@clin.au.dk
Affiliations
Research Center for Emergency Medicine, Department of Clinical Medicine,
Aarhus University Hospital, Denmark (M.J.H., L.W.A.). Center for Resuscitation
Science, Department of Emergency Medicine (M.J.H., A.V.G., T.Y., M.W.D.,
L.W.A.) and Division of Pulmonary, Critical Care, and Sleep Medicine, Depart-
ment of Internal Medicine (M.W.D.), Beth Israel Deaconess Medical Center,
Boston, MA. Division of Medicine Critical Care, Department of Medicine, Bos-
ton Children’s Hospital (C.E.R.) and Department of Psychiatry (G.F.), Harvard
Medical School, MA. Department of Biostatistics, Harvard T.H. Chan School of
Public Health, Boston, MA (G.F.). Laboratory for Psychiatric Biostatistics, McLean
Hospital, Belmont, MA (G.F.). St Luke’s Mid America Heart Institute, the Univer-
sity of Missouri, Kansas City (P.S.C.). Division of Health Sciences Informatics,
Department of Anesthesiology and Critical Care Medicine, School of Medicine,
The Johns Hopkins University, Baltimore, MD (J.D.-A.).
Acknowledgments
Drs Holmberg and Andersen were responsible for data acquisition, performed
the statistical analyses, and drafted the article. All authors contributed to the de-
sign of the study, interpreted the results, critically revised the article, approved the
final article as submitted, and agree to be accountable for all aspects of the work.
Sources of Funding
There was no specific funding for this study. Dr Andersen serves as a com-
pensated statistical reviewer for JAMA. Dr Donnino is supported by grant
1K24HL127101-01, and Dr Chan is supported by grant 1R01HL123980 from
the National Heart, Lung, and Blood Institute.
Disclosures
None.
APPENDIX
Get With The Guidelines-Resuscitation Investigators: Besides the authors Paul
Chan, MD, MSc and Anne V. Grossestreuer, PhD, members of the Get With
The Guidelines-Resuscitation Adult Research Task Force include: Ari Moskowitz,
MD; Dana Edelson, MD, MS; Joseph Ornato, MD; Katherine Berg, MD; Mary
Ann Peberdy, MD; Matthew Churpek, MD, MPH, PhD; Michael Kurz, MD, MS-
HES; Monique Anderson Starks, MD, MHS; Saket Girotra, MBBS, SM; Sarah
Perman, MD, MSCE; Zachary Goldberger, MD, MS. Besides the author Jordan
Duval-Arnould, MPH, DrPH, members of the Get With The Guidelines-Resus-
citation Pediatric Research Task Force include: Anne-Marie Guerguerian, MD,
PhD, FRCPC; Dianne Atkins, MD; Elizabeth Foglia, MD, MSCE; Ericka Fink,
MD; Javier J. Lasa, MD, FAAP; Joan Roberts, MD; Melanie Bembea, MD, MPH;
Michael Gaies, MD, MPH, MSc; Monica Kleinman, MD; Punkaj Gupta, MBBS;
Robert Sutton, MD, MSCE; Taylor Sawyer, DOMed.
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