Disparities in Survival After In-Hospital Cardiac Arrest by Time of Day and Day of Week: A Single-Center Cohort Study

Background: In-hospital cardiac arrest (IHCA) constitutes a high-impact clinical event, associated with substantial mortality, frequent neurological and functional impairment. There is a pressing need for primary IHCA studies that evaluate risk predictors, given the inherent challenges of IHCA data collection, previously unharmonized reporting frameworks, and the predominant focus of prior investigations on other domains. Among potential contributors, the "off-hours effect" has consistently been linked to poorer IHCA outcomes. Accordingly, we sought to examine whether in-hospital mortality after IHCA varies according to the time and day of occurrence within a tertiary academic center in Northern Greece. Methods: We conducted a single-center observational cohort study using a prospectively maintained in-hospital resuscitation registry at AHEPA University General Hospital, Thessaloniki. All adults with an index IHCA between 2017 and 2019 were included, and definitions followed Utstein-style recommendations. Results: Multivariable logistic regression adjusted for organizational, patient, and process-of-care factors demonstrated that afternoon/night arrests, weekend arrests, heart failure comorbidity, and need for mechanical ventilation were independent predictors of higher in-hospital mortality. Conversely, arrhythmia as the cause of IHCA and arrests occurring in the intensive care unit or operating room were associated with improved survival. Subgroup analyses confirmed consistent off-hours differences, with weekend events showing reduced 30-day and 6-month survival and worse functional status at discharge. Afternoon/night arrests were more frequent, characterized by longer response intervals and lower survival at both time points. Conclusions: Organizational factors during nights and weekends, rather than patient case mix, drive poorer IHCA outcomes, underscoring the need for targeted system-level improvements.