Association between patient race and staff resuscitation efforts after cardiac arrest in outpatient dialysis clinics: A study from the CARES surveillance group

Abstract

Background

Cardiac arrest is the leading cause of death among patients receiving hemodialysis. Despite guidelines recommending CPR training and AED presence in dialysis clinics, rates of CPR and AED use by dialysis staff are suboptimal. Given that racial disparities exist in bystander CPR administration in non-healthcare settings, we examined the relationship between patient race/ethnicity and staff-initiated CPR and AED application within dialysis clinics.

Methods

We analyzed data prospectively collected in the Cardiac Arrest Registry to Enhance Survival across the U.S. from 2013 to 2017 and the Centers for Medicare & Medicaid Services dialysis facility database to identify outpatient dialysis clinic cardiac arrest events. Using multivariable logistic regression models, we examined relationships between patient race/ethnicity and dialysis staff-initiated CPR and AED application.

Results

We identified 1568 cardiac arrests occurring in 809 hemodialysis clinics. The racial/ethnic composition of patients was 31.3% white, 32.9% Black, 10.7% Hispanic/Latinx, 2.7% Asian, and 22.5% other/unknown. Overall, 88.0% of patients received CPR initiated by dialysis staff, but rates differed by race: 91% of white patients, 85% of black patients, and 77% of 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 staff-initiated CPR. No significant difference between staff-initiated CPR rates among white, Hispanic/Latinx, and other/unknown patients was observed. An AED was applied by dialysis staff in 62% of patients. In adjusted models, there was no relationship between patient race/ethnicity and staff AED application.

Conclusions

Black and Asian patients are significantly less likely than white patients to receive CPR from dialysis staff. Further understanding of practices in dialysis clinics and increased awareness of this disparity are necessary to improve resuscitation practices.

Introduction

Over 72,500 people in the U.S. have end-stage renal disease (ESRD) and more than 450,000 require maintenance hemodialysis. Hemodialysis patients experience sudden cardiac arrest at rates more than 20 times greater than in the general population.1, 2, 3 Out-of-hospital cardiac arrest (OHCA) occurs most frequently on hemodialysis days and often occurs within outpatient dialysis clinics; an average-sized dialysis clinic experiences approximately one in-clinic cardiac arrest per year.4, 5, 6 Outcomes following dialysis clinic OHCA are poor, with 56% survival to hospital admission, 24% survival to hospital discharge, and 8% one-year survival.⁶

Early provision of cardiopulmonary resuscitation (CPR) and rapid defibrillation by bystanders significantly increase the chance of OHCA survival.7, 8 A recent study of OHCAs occurring in 158 U.S. outpatient hemodialysis clinics found that CPR initiated by dialysis staff was associated with a three-fold higher odds of survival; however, the study also found that dialysis staff did not initiate CPR in nearly 1 out of every 5 cases and did not apply a defibrillator in almost half of cases.⁹

Racial and ethnic minorities are less likely than white individuals to receive bystander CPR in non-healthcare settings.10, 11, 12, 13, 14, 15 Additionally, rates of bystander CPR vary according to neighborhood characteristics, with lower rates within low-income, black-predominant neighborhoods.16, 17, 18, 19, 20, 21 Within the hemodialysis population, racial disparities are well documented; compared with white patients, racial and ethnic minorities have a higher risk of developing ESRD¹ and are less likely to receive optimal treatments for ESRD, including the use of arteriovenous fistulas²² and kidney transplantation.23, 24

In this study, we examined whether patient race/ethnicity is associated with resuscitation efforts within outpatient dialysis clinics. We hypothesized that Black and Hispanic/Latinx patients would be less likely that white patients to receive bystander CPR and AED application from dialysis staff. Secondarily, we sought to examine the association between dialysis clinic characteristics, including clinic neighborhood characteristics, and the likelihood of staff-initiated CPR and AED application.