In-Hospital Cardiac Arrest in a Resource-Limited Emergency Department: Clinical Characteristics, Outcomes, and Predictors of Return of Spontaneous Circulation in Somalia

Technical Summary: In-Hospital Cardiac Arrest in a Resource-Limited Emergency Department in Somalia

Problem Statement
In-hospital cardiac arrest (IHCA) remains a leading cause of hospital mortality globally, with survival rates varying significantly based on healthcare system capacity. While high-income countries have improved outcomes through rapid response systems and specialized post-arrest care, low- and middle-income countries (LMICs), particularly in sub-Saharan Africa, face disproportionately poor outcomes due to delayed recognition of deterioration, limited monitoring, and workforce shortages. In Somalia, data regarding the epidemiology, clinical characteristics, and outcomes of IHCA are virtually nonexistent. This evidence gap hinders the evaluation of resuscitation performance and the development of targeted interventions to improve survival in this resource-constrained setting.

Methodology
This study employed a prospective observational design conducted between January 1, 2024, and July 1, 2025, at the emergency department of the Mogadishu Somali–Turkey Recep Tayyip Erdoğan Training and Research Hospital, a tertiary referral center.

• Population: The study consecutively included 240 adult patients (≥18 years) who experienced IHCA. Patients with documented do-not-resuscitate (DNR) orders or incomplete medical records were excluded.
• Data Collection: A standardized structured form was used to collect demographic data, admission diagnoses, comorbidities, and physiological parameters (blood pressure, heart rate, oxygen saturation, Glasgow Coma Scale, glucose, temperature) at the time of arrest.
• Variables: Key variables included arrest location (ED, ICU, operating theater), witness status, time of occurrence, activation of emergency response teams, time to CPR initiation, duration of resuscitation, and Return of Spontaneous Circulation (ROSC).
• Statistical Analysis: Descriptive statistics summarized patient characteristics. Univariate and multivariable logistic regression analyses were performed to identify independent predictors of ROSC, with variables having a p-value <0.05 in univariate analysis included in the final model.

Key Results

• Demographics and Etiology: The cohort had a mean age of 46.3 ± 15.2 years, with 56.7% male. Trauma was the leading admission diagnosis (58.0%), predominantly severe traumatic brain injury (76.9% of trauma cases). Among comorbidities, HIV infection was most prevalent (45% of those with comorbidities), followed by hypertension (22%).
• Arrest Characteristics: The majority of arrests (83.2%) occurred in the emergency department. A significant proportion of arrests were unwitnessed (63.2%). Emergency response protocols were activated in only 22.6% of cases, and CPR was initiated in 14.6% of patients.
• Outcomes: The rate of Return of Spontaneous Circulation (ROSC) was extremely low at 7.4% (14 patients). Survival beyond 24 hours was minimal, at 1.6% (3 patients). ROSC rates varied by location: 45.5% in the operating theater, 25.0% in the ICU, and only 2.5% in the emergency ward.
• Predictors of Poor Outcomes: Multivariable analysis identified several independent factors associated with reduced odds of ROSC:
  • Trauma as admission diagnosis (OR 0.12; 95% CI 0.03–0.45).
  • Sepsis as admission diagnosis (OR 0.14; 95% CI 0.04–0.52).
  • HIV infection (OR 0.10; 95% CI 0.01–0.72).
  • Arrest occurring in the Emergency Department (OR 0.10; 95% CI 0.02–0.46).
  • Weekend presentation (OR 0.20; 95% CI 0.04–0.09).
  • No significant associations were found with age, sex, or time of day (day vs. night).

Significance and Claims
The authors assert that this study represents one of the first prospective investigations of IHCA in Somalia, addressing a critical gap in emergency care research within the region. The study provides real-world evidence demonstrating that IHCA outcomes in this resource-limited setting are "extremely poor," with survival rates far below those reported in high-income countries and even lower than some other sub-Saharan African studies.

The paper claims its significance lies in identifying specific, context-dependent predictors of mortality—namely the high burden of trauma, the prevalence of sepsis and HIV, the high frequency of unwitnessed arrests, and the "weekend effect." These findings highlight systemic deficiencies in early recognition, continuous monitoring infrastructure, and resuscitation capacity. The authors conclude that improving survival requires urgent strengthening of early warning systems, enhanced CPR training, rapid activation of emergency response teams, and expanded access to monitoring and critical care resources. They note that future multicenter studies are necessary to further characterize IHCA epidemiology and evaluate targeted interventions.

Limitations
The authors acknowledge several limitations, including the single-center design which may limit generalizability, inconsistent documentation of advanced resuscitation variables (e.g., initial cardiac rhythm, defibrillation timing) due to resource constraints, and the lack of long-term outcome data (survival to discharge and neurological status). Additionally, incomplete documentation of clinical variables in some patients reflects the inherent challenges of conducting high-acuity research in resource-limited environments.