Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital 'Utstein style'. A statement for healthcare professionals from the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa

Reliability testing and update of the Resuscitation Predictor Scoring (RPS) Scale

OBJECTIVES

The purpose of this study was to test the reliability of the Resuscitation Predictor Scoring (RPS) Scale1 (Appendix A), a survival prediction nomogram designed to aid resuscitation termination decisions during a resuscitation attempt.

METHOD

Bivariate comparisons of predictors of survival and survival rates between the primary RPS Scale data set (1993-2000) and a secondary data set (2000-2003). A total of 2121 patients were included in the study.

RESULTS

Comparisons of the two sets of data showed an increase in resuscitation attempts for patients > or =80 years (p<0.001); an increase in pulseless electrical activity (PEA) (p=0.01) and an increase in the duration of arrests (p=0.012). However, in relation to the RPS Scale there were no statistical differences in survival between any of the sub groups demonstrating the reliability of the nomogram.

CONCLUSION

The final updated RPS Scale demonstrates predicted survival rates 15 min into a resuscitation attempt. These can be poor and suggest that it is an acceptable point at which to first consider termination (where there has been no ROSC). The RPS Scale has demonstrated reliability and validity, but can only be a guide for the cessation of resuscitation.

Electrical defibrillation: new technologies

Two-thirds of deaths from coronary disease occur in the pre-hospital phase and are caused by ventricular fibrillation or pulseless ventricular tachycardia, for which electrical defibrillation is the only effective treatment. The time delay between the onset of ventricular fibrillation and the administration of the first defibrillatory shock is the most important determinant for survival. To achieve the earliest defibrillation possible, rescuers others than physicians need to be able to initiate this treatment. The international scientific community strongly supports the concept of early defibrillation in the setting of a strong chain of survival. New technological developments of automated external defibrillators (AEDs) allowed the implementation of defibrillation by the first responding professional rescuer. As a consequence of the technological evolution in implantable defibrillators, much research has also been done on new defibrillation waveforms and alternative energy levels in external defibrillators. After initial animal research, human clinical investigation has shown that initial low energy (150J) nonprogressive (150J-150J-150J) impedance-adjusted biphasic waveform defibrillatory shocks for patients in out-of-hospital ventricular fibrillation are safe, acceptable and clinically effective. Reporting on outcome from cardiac arrest must be as uniform as possible to allow conclusions on performance of emergency medical service systems. The 'Utstein Style' nomenclature is a glossary of terms and a reporting guideline for uniform description of cardiac arrest, resuscitation, the emergency medical service (EMS) system and the outcome. Reports on experiences with AED programmes by traditional and non-traditional professional rescuers support the view that AEDs should not be implemented in EMS systems as an isolated intervention, but that efforts are equally needed to strengthen the other links of the chain of survival. The international scientific community (American Heart Association, International Liaison Committee on Resuscitation and European Resuscitation Council) have issued guidelines for the use of AEDs by EMS providers and first responders, and a universal treatment algorithm is proposed.

False cardiac arrests: the right time to turn away?

AIM

Cardiac arrest teams may be activated only to find that the patient does not require cardiac or respiratory resuscitation. Members of the cardiac arrest team are drawn from medical personnel with other responsibilities who may disperse quickly, leaving ongoing care of the patient to existing ward staff. The outcome for such false cardiac arrests, however, is rarely reported. The objective of this study was to determine the causes of false cardiac arrest team alerts (FCAs) and to assess the outcome of these patients relative to the general hospital population.

SETTING

Tertiary care hospital.

PARTICIPANTS

Patients subject to a cardiac arrest call who were found not to require basic or advanced cardiac life support on arrival.

RESULTS

In 512 events over a 1-year period, patients suffering FCAs were more likely to survive compared to patients suffering cardiac arrest (15% vs 73%, odds ratio (OR) 14.95; chi2 p< or =0.0001), but significantly less likely to survive than the general hospitalised population (73% vs 97%, OR 14.15; chi2 p< or =0.0001). The cause of the FCA was often minimised as collapse or vasovagal syncope; in 58% (87/150) of cases no further action was taken by the attending medical team. Patients suffering FCAs tended to be long-stay patients with a worse outcome at weekends.

CONCLUSION

In areas lacking a medical alert, outreach or patient at risk system, particular attention should be paid to optimising care of those suffering FCAs.

Improving Survival After In-Hospital Cardiac Arrest: The Australian Experience

Background Survival rates after in-hospital cardiac arrest have not improved markedly despite improvements in technology and resuscitation training.

Objectives To investigate clinical variables that influence return of spontaneous circulation and survival to discharge after in-hospital cardiac arrest.

Methods An Utstein-style resuscitation template was implemented in a 750-bed hospital. Data on 158 events were collected from January 2004 through November 2004. Significant variables were analyzed by using a multiple logistic regression model.

Results Of the 158 events, 128 were confirmed cardiac arrests. Return of spontaneous circulation occurred in 69 cases (54%), and the patient survived to discharge in 41 (32%). An initial shockable rhythm was present in 42 cases (33%), with a return of spontaneous circulation in 32 (76%) and survival to discharge in 24 (57%). An initial nonshockable rhythm was present in the remaining 86 cases (67%), with a return of spontaneous circulation in 37 (43%) and survival to discharge in 17 (20%). Witnessed or monitored arrests (P=.006), time to arrival of the cardiac arrest team (P=.002), afternoon shift (P=.02), and initial shockable rhythm (P=.005) were independently associated with return of spontaneous circulation. Location of patient in a critical care area (P=.002), initial shockable rhythm (P&lt;.001), and length of resuscitation (P=.02) were independently associated with survival to hospital discharge.

Conclusions The high rate of survival to discharge after cardiac arrest is attributed to extensive education and the incorporation of semiautomatic external defibrillators into basic life support management.

Variability in survival after in-hospital cardiac arrest depending on the hospital level of care

BACKGROUND

Survival after in-hospital cardiac arrest (IHCA) differs considerably between hospitals. This study tries to determine whether this difference is due to patient selection because of the hospital level of care or to effective resuscitation management.

METHODS

Prospectively collected data on management of in-hospital cardiac arrests from Sahlgrenska Hospital, a tertiary hospital in Gothenburg, Sweden (cohort one) and from five Finnish secondary hospitals (cohort two). A multiple logistic regression model was created for predicting survival to hospital discharge.

RESULTS

A total of 954 cases from Sahlgrenska Hospital and 624 patients from the hospitals in Finland were included. The delay to defibrillation was longer at Sahlgrenska than at the five Finnish secondary hospitals (p=0.045). Significant predictors of survival were: (1) age below median (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.5-2.8); (2) no diabetes (OR 1.9, CI 1.2-2.9); (3) arrests occurring during office hours (OR 1.5, CI 1.1-2.2); (4) witnessed cardiac arrest (OR 6.3, CI 2.6-15.3); (5) ventricular fibrillation or ventricular tachycardia as the initial rhythm (OR 4.9, CI 3.5-6.7); (6) location of the arrest (compared to arrests in general wards, GW): thoracic surgery and heart transplantation ward (OR 2.9, CI 1.5-5.9), interventional radiology (OR 4.8, CI 1.9-12.0) and other in-hospital locations (3.0, CI 1.6-5.7) and (7) hospital (compared to arrests at Sahlgrenska Hospital); arrests at Etelä-Karjala Central Hospital [CH] (OR 0.3, CI 0.1-0.7), Päijät-Hame CH (OR 0.3, CI 0.1-0.8) and Seinäjoki CH (OR 0.4, CI 0.3-0.7).

CONCLUSION

The comparison of survival following IHCA between different hospitals is difficult, there seems to be undefined factors greatly associated with outcome. A great variability in survival within different hospital areas probably because of differences in patient selection, patient surveillance and resuscitation management was also noted. A locally implemented strong in-hospital chain of survival is probably the only way to improve outcome following IHCA.

Advanced cardiac life support training improves long-term survival from in-hospital cardiac arrest

CONTEXT

Advanced cardiac life support (ACLS) training was introduced to bring order and a systematic approach to the treatment of cardiac arrest by professional responders. In spite of the wide dissemination of ACLS training, it has been difficult to demonstrate improved outcome following such training.

OBJECTIVE

To determine the value of formal ACLS training in improving survival from in-hospital cardiac arrest.

DESIGN, SETTING, AND PARTICIPANTS

A multi-center, prospective cohort study examined patient outcomes after resuscitation efforts by in-hospital rescue teams with and without ACLS-trained personnel. A total of 156 patients, experiencing 172 in-hospital cardiopulmonary arrest events over a 38-month period (January 1998 to March 2001) were studied.

MAIN OUTCOME MEASURES

Primary endpoints included return of spontaneous circulation (ROSC), survival to hospital discharge, 30-day survival, and 1-year survival.

RESULTS

The immediate success of resuscitation efforts for all patients was 39.7% (62/156). There was a significant increase in ROSC with ACLS-trained personnel (49/113; 43.4%) versus no ALCS-trained personnel (16/59; 27.1%; p=0.04). Likewise, patients treated by ACLS-trained personnel had increased survival to hospital discharge (26/82; 31.7% versus 7/34; 20.6%; p=0.23), significantly better 30-day survival (22/82; 26.8% versus 2/34; 5.9%; p<0.02), and significantly improved 1-year survival (18/82; 21.9% versus 0/34; 0%; p<0.002).

CONCLUSION

The presence of at least one ACLS-trained team member at in-hospital resuscitation efforts increases both short and long-term survival following cardiac arrest.

Clinical review: beyond immediate survival from resuscitation-long-term outcome considerations after cardiac arrest

A substantial body of literature concerning resuscitation from cardiac arrest now exists. However, not surprisingly, the greater part concerns the cardiac arrest event itself and optimising survival and outcome at relatively proximal time points. The aim of this review is to present the evidence base for interventions and therapeutic strategies that might be offered to patients surviving the immediate aftermath of a cardiac arrest, excluding components of resuscitation itself that may lead to benefits in long-term survival. In addition, this paper reviews the data on long-term impact, physical and neuropsychological, on patients and their families, revealing a burden that is often underestimated and underappreciated. As greater numbers of patients survive cardiac arrest, outcome measures more sophisticated than simple survival are required.

Nuevas recomendaciones para el registro uniforme de datos en la reanimación cardiopulmonar avanzada. Estilo Utstein pediátrico

Pediatric patients requiring cardiopulmonary resuscitation show high morbidity and mortality. There are few studies on this topic and existing studies use distinct terminology and methodology in data collection, hampering comparisons, efficiency assessment, and meta-analyses, etc. Consequently, in clinical studies of cardiorespiratory arrest (CRA) and cardiopulmonary resuscitation (CPR) in the pediatric age group, data collection should be performed in a uniform manner. To define the criteria that allow uniform data collection, in 2004 a working group of the International Liaison Committee on Resuscitation published simplified recommendations for registering essential information, which could be applicable to adults and children both in clinical practice and research, as well as inside and outside the hospital setting. Following the Utstein style, the Spanish Group of Pediatric and Neonatal CPR has designed an algorithm and a data collection form for recording essential CPA data. The need for these documents to be designed with maximum accuracy is stressed, both because of their medico-legal and professional implications and because of the influence of some variables on post-CPA recovery. Likewise, while protecting patient confidentiality, provincial, regional and national CPA registries should be developed, which would improve the quality of care, research, and resource provision according to needs.

Ética y reanimación cardiopulmonar pediátrica

Cardiopulmonary resuscitation (CPR) is a medical activity that involves major ethical issues. As in other areas of clinical ethics, CPR decisions must be based on the principles of autonomy, beneficence, nonmaleficence, and justice. The decision-making process is more difficult in emergency situations, and when the patient is a minor, the parents and the child's best interests must be taken into consideration. There are specific situations in which starting CPR is clearly indicated and others in which ceasing resuscitation maneuvers is justified. Do not attempt resuscitation orders must be respected by health staff. Other ethical issues involved in CPR include resuscitation of potential organ donors, learning CPR procedures, research in CPR, and the information given to the parents of children with cardiorespiratory arrest.

Reflection on a patient's airway management during a ward-based resuscitation

BACKGROUND

The bag-valve-mask (BVM) system is a common adjunct used during adult resuscitation to ventilate the lungs and deliver oxygen to patients in cardiopulmonary arrest. Gastric inflation, regurgitation and aspiration are well-documented complications of BVM ventilation, which can have serious consequences for patients.

AIM

The aim of this paper is to review the cause of gastric inflation, regurgitation and aspiration during BVM ventilation and to consider techniques that have been suggested to reduce these problems.

METHOD

Using a reflective model, the author revisits an actual cardiac arrest, and within a structured framework considers the event itself, the context of the event and looks at ways in which practice could be improved in future.

RESULTS

It is clear from the evidence that a reduction in peak airway pressure can reduce the risk of gastric inflation, regurgitation and aspiration. A review of the available research strongly suggests that in expert hands, the most effective means of reducing peak airway pressure is by reducing tidal volume by using a smaller bag.

CONCLUSION

Although the evidence, as presented, for a reduction in bag size is convincing, there appears to be a problem that less regular users do not appear to be able to produce effective tidal volumes when using a smaller bag. If a reduced bag size is standardized, further research using a diverse group of health care workers with the BVM is required before a clear policy can be achieved. It is likely that training and practice will be shown to be important for nursing staff expected to use the smaller BVM.

Increase in rapid defibrillation programmes after publication of guidelines

OBJECTIVE

. To monitor the implementation of in-hospital resuscitation strategies including (i) rapid defibrillation programmes, (ii) the use of amiodarone for prolonged ventricular fibrillation, and (iii) uniform data collection on resuscitation, all recommended by international guidelines published in 2000 and by Finnish national resuscitation guidelines published in 2002.

DESIGN

In 2004, a questionnaire was sent to the chief anaesthesiologists. The results were compared with those of a previous study performed using similar methods in 2000.

SETTING

All public hospitals that provide anaesthetic services in Finland.

MAIN OUTCOME MEASURES

Number of hospitals allowing nurses to perform defibrillation without the presence of physician and number of hospitals using amiodarone as primary antiarrhythmic drug in resuscitation and performing uniform data collection.

RESULTS

The response rate was 95% (52/55). The proportion of the hospitals with rapid defibrillation programmes on general wards had increased from 15% in 2000 to 67% in 2004, and most (79%) hospitals had obtained automated external defibrillators. Amiodarone was used in 88% of the hospitals. Data collection of resuscitation attempts using definitions provided in the Utstein guidelines was performed only in 22% of the hospitals.

CONCLUSIONS

Rapid defibrillation programmes have markedly increased, and the use of amiodarone has been established in Finnish hospitals since the publication of the international and the national resuscitation guidelines.

[Definitions and prevention of cardiorespiratory arrest in children]

In cardiopulmonary resuscitation ages are divided in neonates (in the inmediate period after the birth), infant (from birth to 12 months) and child (from 12 months to puberty). Respiratory arrest is defined by the absence of spontaneous respiration (apnea) or a severe respiratory insufficiency (agonal gasping) that require respiratory assistance. Cardiac arrest is defined as the absence of central arterial pulse or signs of circulation (movement, cough or normal breathing) or the presence of a central pulse less than 60 lpm in a child who does not respond, not breath and with poor perfusion. After resuscitation the return of spontaneous circulation is defined as the recuperation of central arterial pulse or signs of circulation in a child with previous cardiorespiratory arrest. It is maintained when the duration is longer than 20 minutes. Injuries, sudden infant death syndrome, and respiratory diseases are the most frequent etiologies of cardiorrespiratory arrest in children. The prevention and the formation of citizens in basic cardiopulmonary resuscitation are the most effective measures to reduce the mortality of cardiorespiratory arrest in children.

Effectiveness and long-term outcome of cardiopulmonary resuscitation in paediatric intensive care units in Spain

OBJECTIVE

To analyse the immediate effectiveness of resuscitation and long-term outcome of children who suffered a cardiorespiratory arrest when admitted to paediatric intensive care units (PICU).

DESIGN AND SETTING

Secondary analysis of data from an 18-month prospective, multicentre study analysing cardiorespiratory arrest in children in 16 paediatric intensive care units in Spain.

PATIENTS AND METHODS

We studied 116 children between 7 days and 17 years of age. Data were recorded according to the Utstein style. Analysed outcome variables were sustained return of spontaneous circulation (ROSC), survival to hospital discharge and survival at 1 year. Neurological and general performance outcome was assessed by means of the Paediatric Cerebral Performance Category (PCPC) and the Paediatric Overall Performance Category (POPC) scales.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

In 80 patients (69%) ROSC was achieved and it was sustained > 20 min in 69 (59.5%). At one-year follow-up, 40 children (34.5%) were alive. Survival was not associated with sex, age or weight of patients. Mortality from cardiac arrest was higher than respiratory arrest (69.8% versus 40%, p = 0.01). Patients with sepsis had a higher mortality than other diagnostic groups. Mechanically ventilated children and those treated with vasoactive drugs had a higher mortality. Initial mortality was slightly higher in patients with slow ECG rhythms (35.7%) compared to those with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) (27.2%). Duration of resuscitation effort was correlated with mortality (p < 0.0001). Patients who required one or more doses of adrenaline had also a higher mortality (77.8% versus 20.7%, p < 0.0001) and survivors needed less doses of adrenaline (0.85 +/- 1.14 versus 4.4+/-2.9, p < 0.0001). At hospital discharge 86.8 and 84.6% of patients had scores 1 or 2 (normal or near-normal) in the PCPC and POPC scales. At 1-year follow-up these figures were 90.8 and 86.3%, respectively.

CONCLUSION

One-third of children who suffer a cardiac or respiratory arrest when admitted to PICU survive, and most of them had a good long-term neurological and functional outcome. The duration of cardiopulmonary resuscitation attempts is the best indicator of mortality.

Reduced survival following resuscitation in patients with documented clinically abnormal observations prior to in-hospital cardiac arrest

BACKGROUND

Patients suffering in-hospital cardiac arrest (IHCA) often have abnormal clinical observations documented prior to the arrest. This study assesses whether these patients have a less favourable outcome following IHCA.

METHODS

A multiple logistic regression analysis of retrospectively collected hospital chart data and prospectively collected Utstein style resuscitation data. Patients were defined as having abnormal clinical observations if they had one of the following documented 8 h before the arrest: systolic arterial blood pressure below 90 or over 200, pulse rate below 40 or over 140 beats per min or oxygen saturation below 90% with or without supplemental oxygen. Pre-arrest variables included were: age, sex and functional status, co-morbidities, reason for hospital admission, days in the hospital before the arrest, witnessed or un-witnessed arrest, arrest occurring outside regular working hours, monitored or non-monitored ward, whether basic life support was performed before the arrival of the resuscitation team, delay to arrival of resuscitation team and initial rhythm.

RESULTS

Survival to hospital discharge of patients with clinically abnormal observations was 9% and among those without 18% (p=0.037). Independent pre-arrest predictors of survival were: un-witnessed arrest (odds ratio [OR] 0.1, confidence interval (CI) 0.01-0.8), initial rhythm other than ventricular fibrillation or ventricular tachycardia (OR 0.13, CI 0.05-0.3), delay to arrival of the resuscitation team exceeding 2 min (median) (OR 0.4, CI 0.15-0.9) and the presence of documented clinical abnormal observations prior to the arrest (OR 0.3, CI 0.09-0.95).

CONCLUSIONS

Patients with documented clinically abnormal observations before IHCA have a worse outcome than those without, despite prompt resuscitation. Efforts should be made to identify these patients in time, thereby possibly avoiding the arrest. This can also be used when assessing the prognosis in IHCA.

In-hospital cardiac arrest--an Utstein style report of seven years experience from the Sahlgrenska University Hospital

BACKGROUND

In-hospital cardiac arrest is one of the most stressful situations in modern medicine. Since 1997, there has been a uniform way of reporting - the Utstein guidelines for in-hospital cardiac arrest reporting.

MATERIAL AND METHODS

We have studied all consecutive cardiac arrest in the Sahlgrenska University Hospital (SU) between 1994 and 2001 for who the rescue team was alerted in all 833 patients. The primary endpoint for this study was survival to discharge.

RESULTS

Thirty-seven percent survived to hospital discharge. Among patients who were discharged alive, 86% were alive 1 year later. The survivors have a good cerebral outcome (94% among those who were discharged alive had cerebral performance category (CPC) score 1 or 2). The organization at SU is efficient; 80% of the cardiac arrest had CPR within 1 min. Time from cardiac arrest to first defibrillation is a median of 2 min. Almost two-thirds of the patients were admitted for cardiac related diagnoses.

CONCLUSION

The current study is the largest single-centre study of in hospital cardiac arrest reported according to the Utstein guidelines. We report a high survival for in-hospital cardiac arrest. We have pointed out that a functional chain of survival, short intervals before the start of CPR and defibrillation are probably contributing factors for this.

Inconsistencies in cardiac arrest reporting

Data relating to survival from in-hospital cardiac arrest are used to audit staff performance and to help to determine whether new resuscitation techniques are effective. Individual studies into outcome from cardiac arrest have defined inclusion and exclusion criteria, but no such national criteria have been published to enable constant auditing of cardiac arrests. The aim of this survey was to investigate the consistency with which in-hospital cardiac arrests are recorded throughout the United Kingdom. Such data are, almost universally, collected by Resuscitation Officers (RO). A questionnaire was sent to ROs across the UK asking them to state how they would interpret and categorise hypothetical, but nonetheless typical, clinical situations involving a cardiac arrest team being called. These included an event where the patient had regained consciousness prior to the arrival of the cardiac team and also an event where rigor mortis was already present and the resuscitation promptly abandoned upon the arrival of the cardiac arrest team. The percentage survival to discharge of adult cardiac arrests for each hospital was also requested. This identified whether inclusion or exclusion of certain clinical events may have influenced cardiac arrest survival figures for that hospital. It is clear from this study that in-hospital clinical events when a cardiac arrest team is called are audited with a great deal of inconsistency. Some events, such as a patient who has rigor mortis, are excluded as a false or inappropriate call in some hospitals and included as an unsuccessful resuscitation in others. There is a need for guidance on the inclusion and exclusion criteria for auditing of cardiac arrests so that meaningful data can be obtained from across the UK and useful conclusions drawn. The situation at present will result in data being audited that are of limited use. In the era of evidence-based medicine, it seems vital to obtain accurate cardiac arrest survival figures in order to have any hope of improving them.

Long-term survival and residual hazard after in-hospital cardiac arrest

AIM

The purpose of this study was to determine long-term survival after in-hospital cardiac arrests and to explore if and when the excess mortality risk imposed by the index event reaches that of an age and sex matched general population.

METHOD

A retrospective analysis of data from 1,571 in-hospital cardiac arrests between the calendar years 1997 and 2002 inclusive was performed. Two hundred and fifty-nine people survived until hospital discharge, 220 of which were residents in England and included in the study. Kaplan-Meier curves were constructed for the survivors and an age and sex matched comparator population, and survival compared with a one-sample log rank test. Smoothed hazard curves were constructed for the two populations. Differences in outcome from year of index event were also sought.

RESULTS

16.5% of patients survived to hospital discharge. Patients continue to experience a mortality rate greater than that of the comparator population during the first 200 days, with overall 70 deaths versus 18.7 as predicted from life tables (p < 0.0001). The hazard is greatest after resuscitation and falls thereafter until about 2 years where it is not very different to that of the comparator population and then subsequently rises. No evidence was found of a difference in the first year survival between patients resuscitated in different calendar years (p > 0.3 for all tests).

CONCLUSION

The residual risk to an individual cardiac arrest survivor's life is greatest during the first year of survival, but declines progressively during the first 2 years after the event, subsequently approaching the risk experienced by the general population.

Improved survival after in-hospital cardiac arrest outside critical care areas

BACKGROUND

The in-hospital Utstein Guidelines may be used to evaluate resuscitation strategies. This study utilized the Utstein template prospectively to examine changes in outcome and outcome-related factors after resuscitation outside critical care areas over a 10-year period.

METHODS

Seinäjoki Central Hospital (460 beds) is a secondary hospital in Finland with acute care activities. In 1993, the in-hospital cardiac arrest management was remodelled; an intensive care unit-based resuscitation team was formed and prospective data collection began (modified according to the Utstein Guidelines in 1997). An analysis of resuscitation attempts outside critical care areas between 1993 and 2002 was performed. To monitor developments, the patients were divided into two groups (first period, 1993-97; second period, 1998-2002). Variables independently associated with survival were identified using multiple logistic regression analysis.

RESULTS

During the 10-year period, resuscitation was attempted in 183 patients. Survival to discharge was 6% during the first period and 16% during the second (P = 0.048). The corresponding figures for survival at 1 year from the event were 3% and 10% (P = 0.064). Independent predictors of survival were ventricular fibrillation or ventricular tachycardia as the initial rhythm [odds ratio (OR), 9.8; confidence interval (CI), 3.2-30.3] and cardiac arrest occurring during the second period (OR, 3.3; CI, 1.1-10.1).

CONCLUSION

Prospective Utstein style data collection proved to be a valuable tool for the evaluation of management and outcome following in-hospital cardiac arrest. Increased survival was seen over 10 years outside critical care areas. Organizational changes, including cardiopulmonary resuscitation training for ward personnel and standardized resuscitation management, may have contributed to this change.

Systematic review of definitions for drowning incidents

OBJECTIVES

In preparation for the World Congress on Drowning uniform reporting consensus document of drowning incidents we reviewed systematically the medical literature for the terms and definitions used to describe drowning incidents to assess the uniformity of these terms in the medical literature.

METHODS

The search strategy included a literature search of PubMed, MEDLINE and the Cochrane Database from 1966 to April 2002, as well as a review of reference lists of identified studies and a hand search of relevant textbooks and reference works. Search terms used included drowning, near-drowning, submersion, immersion, suffocation, asphyxiation, water injuries, and aspiration. Any article with drowning as a primary focus and containing a definition of drowning was included. Study designs included experimental studies, observational studies, case control studies, reviews, letters, and editorials.

RESULTS

The search identified approximately 6000 articles. Of these 650 were reviewed and 43 articles addressing the definition of drowning were identified. We found a total of 33 different definitions to describe drowning incidents, 20 for drowning and 13 for near-drowning; along with another 13 related terms. There were at least 20 different outcome measures for drowning incidents reported.

CONCLUSIONS

A review of existing drowning literature demonstrates a lack of a standard definition of drowning and a lack of agreement on measures of outcome. This variability in definitions and outcomes makes it very difficult to assess and analyze studies both individually and as a whole and draw conclusions that will influence practice. These objective findings support the need for the drowning Utstein focus on one definition of drowning and validated measures of functional and neurological outcome.

Recommended guidelines for reviewing, reporting, and conducting research on post-resuscitation care: The Utstein style

The aim of this report is to establish recommendations for reviewing, reporting, and conducting research during the post-resuscitation period in hospital. It defines data that are needed for research and more specialised registries and therefore supplements the recently updated Utstein template for resuscitation registries. The updated Utstein template and the out-of-hospital "Chain of Survival" describe factors of importance for successful resuscitation up until return of spontaneous circulation (ROSC). Several factors in the in-hospital phase after ROSC are also likely to affect the ultimate outcome of the patient. Large differences in survival to hospital discharge for patients admitted alive are reported between hospitals. Therapeutic hypothermia has been demonstrated to improve the outcome, and other factors such as blood glucose, haemodynamics, ventilatory support, etc., might also influence the result. No generally accepted, scientifically based protocol exists for the post-resuscitation period in hospital, other than general brain-oriented intensive care. There is little published information on this in-hospital phase. This statement is the result of a scientific consensus development process started as a symposium by a task force at the Utstein Abbey, Norway, in September 2003. Suggested data are defined as core and supplementary and include the following categories: pre-arrest co-morbidity and functional status, cause of death, patients' quality of life, in-hospital system factors, investigations and treatment, and physiological data at various time points during the first three days after admission. It is hoped that the publication of these recommendations will encourage research into the in-hospital post-resuscitation phase, which we propose should be included in the chain-of-survival as a fifth ring. Following these recommendations should enable better understanding of the impact of different in-hospital treatment strategies on outcome.

Cardiopulmonary resuscitation standards for clinical practice and training in the UK

The Royal College of Anaesthetists, the Royal College of Physicians, the Intensive Care Society and the Resuscitation Council (UK) have published new resuscitation standards. The document provides advice to UK healthcare organisations, resuscitation committees and resuscitation officers on all aspects of the resuscitation service. It includes sections on resuscitation training, resuscitation equipment, the cardiac arrest team, cardiac arrest prevention, patient transfer, post-resuscitation care, audit and research. The document makes several recommendations. Healthcare institutions should have, or be represented on, a resuscitation committee that is responsible for all resuscitation issues. Every institution should have at least one resuscitation officer responsible for teaching and conducting training in resuscitation techniques. Staff with patient contact should be given regular resuscitation training appropriate to their expected abilities and roles. Clinical staff should receive regular training in the recognition of patients at risk of cardiopulmonary arrest and the measures required for the prevention of cardiopulmonary arrest. Healthcare institutions admitting acutely ill patients should have a resuscitation team, or its equivalent, available at all times. Clear guidelines should be available indicating how and when to call for the resuscitation team. Cardiopulmonary arrest should be managed according to current national guidelines. Resuscitation equipment should be available throughout the institution for clinical use and for training. The practice of resuscitation should be audited to maintain and improve standards of care. A do not attempt resuscitation (DNAR) policy should be compiled, communicated to relevant members of staff, used and audited regularly. Funding must be provided to support an effective resuscitation service.

Characteristics and outcome of cardiorespiratory arrest in children

OBJECTIVE

To analyse the present day characteristics and outcome of cardio-respiratory arrest in children in Spain.

DESIGN

An 18-month prospective, multicentre study analysing out-of-hospital and in-hospital cardio-respiratory arrest in children.

PATIENTS AND METHODS

Two hundred and eighty-three children between 7 days and 17 years of age with cardio-respiratory arrest. Data were recorded according to the Utstein style. The outcome variables were the sustained return of spontaneous circulation (initial survival), and survival at 1 year (final survival). Three hundred and eleven cardio-respiratory arrest episodes, composed of 70 respiratory arrests and 241 cardiac arrests in 283 children were studied. Accidents were the most frequent cause of out-of-hospital arrest (40%), and cardiac disease was the leading cause (31%) of in-hospital arrest. Initial survival was 60.2% and 1 year survival was 33.2%. The final survival was higher in patients with respiratory arrest (70%) than in patients with cardiac arrest (21.1%) (P <0.0001). Although many individual factors correlated with mortality, multivariate logistic regression revealed that the best indicator of mortality was a duration of cardiopulmonary resuscitation of over 20 min (odds ratio: 10.35; 95% CI 4.59-23.32).

CONCLUSIONS

In Spain, the present mortality from cardio-respiratory arrest in children remains high. Survival after respiratory arrest is significantly higher than after cardiac arrest. The duration of cardiopulmonary resuscitation attempt is the best indicator of mortality of cardio-respiratory arrest in children.

Management following resuscitation from cardiac arrest: Recommendations from the 2003 Rocky mountain critical care conference

PURPOSE

To propose a strategy for the management of patients admitted to critical care units after resuscitation from cardiac arrest.

SOURCE

Prior to the conference relevant studies were identified via literature searches and brief reviews circulated on the following topics: glucose and blood pressure management; therapeutic hypothermia; prearrest outcome prediction; post-arrest outcome prediction; and management of myocardial ischemia. Two days were devoted to assessing evidence and developing a management strategy at the conference. Consensus opinion of conference participants [intensive care unit (ICU) physicians] was used when high grade evidence was unavailable. Additional literature searches and data grading were performed post-conference.

PRINCIPAL FINDINGS

High grade evidence was lacking in most areas. Specific goals of treatment were proposed for: general care; neurologic care; respiratory care; cardiac care; and gastrointestinal care. There was adequate evidence to recommend therapeutic hypothermia for comatose patients who had witnessed ventricular fibrillation or ventricular tachycardia arrests. Conference participants supported extending therapeutic hypothermia to other presenting rhythms in selected circumstances. Additional goals included mean arterial pressure 80 to 100 mmHg, glucose 5 to 8 mmol.L(-1) using insulin infusions, and PaO(2) > 100 mmHg for the first 24 hr. Absent withdrawal to pain 72 hr after resuscitation should prompt consideration of palliative care. The level of evidence for other recommendations was low.

CONCLUSIONS

The proposed management strategy represents an approach to manage patients in the ICU following resuscitation from cardiac arrest. Most of the recommendations are based on low grade evidence. Additional research is needed to improve the evidence base. A standard post-arrest management strategy could help facilitate future research.

Survival from in-hospital cardiac arrest: the potential impact of infection

OBJECTIVE

The aim of this study was to examine the relationship between outcome from cardiac arrest and infection status at the time of in-hospital cardiac arrest.

DESIGN

This was a retrospective database review from a single resuscitation service supporting two major hospitals.

SETTING

Two urban University Hospitals in London.

PATIENTS

Data from 1436 in-patient cardiac arrest were available for analysis.

INTERVENTIONS

Nil.

MEASUREMENTS AND RESULTS

Patients were classified into infected or non-infected groups by the resuscitation audit process and the hospitals diagnostic coding unit. Survival was followed according to the in-hospital Utstein timepoints. In addition, the data were examined by presenting the cardiac rhythm. Age and length of prior hospitalisation were recorded. Infection associated diagnoses appear to be increasing in prevalence. Initial survival from cardiac arrest was not affected by infection status, but this did have a substantial impact on chance of leaving the initial hospital (odds ratio 0.52, confidence intervals 0.3-0.8), or being discharged to home (odds ratio 0.48, confidence intervals 0.4-0.8). The outcome from ventricular fibrillation/pulseless ventricular tachycardia was worse for infected patients (odds ratio for home discharge 0.37, confidence intervals 0.2-0.9), although initial survival was not significantly different.

CONCLUSIONS

Infection may be becoming an increasingly important association with cardiac arrest in the hospitalised population. Initial survival from cardiac arrest is the same as for non-infected patients, but longer term survival is much poorer. Long-term survival from ventricular fibrillation or pulseless ventricular tachycardia is relatively poor, in spite of similar initial success.

Evaluating a Training Program for Pharmacist Code Blue Response

Objective

The purpose of this study was to determine if pharmacy-specific didactic and experiential education could increase pharmacists’ knowledge about code situations and their comfort level in responding to these events. Secondarily, we examined the impact of the program on pharmacists with various prior experience with cardiac arrest resuscitation (code blue events).

Design

Given the extensive use of medications during advanced cardiac life support, pharmacists working on resuscitation teams have a unique opportunity to improve patient care. If properly trained, pharmacists could potentially reduce medication errors, aid in medication preparation, and provide drug and compatibility information. However, a pharmacy-specific education program of this type is not currently available. Before beginning this project, a knowledge assessment and comfort level survey were administered to pharmacists to obtain baseline information about their knowledge of commonly used medications, hospital policies, and perceived comfort levels in performing resuscitation practices. The pharmacists attended an education session about these topics and were given an opportunity to practice medication preparation. Upon completion, each pharmacist repeated the knowledge assessment, a comfort survey, and a competency check list.

Results

Pharmacists’ performance on a written knowledge assessment improved by a mean of 3.5 ± 0.6 questions (P = 0.0001). Perceived comfort level also increased for several aspects of code involvement.

Conclusion

The data suggests that targeted education could increase pharmacists’ knowledge and comfort levels related to resuscitation efforts. Further investigation is required to determine the impact of the program on pharmacist performance during a resuscitation effort.

Cardiopulmonary resuscitation standards for clinical practice and training in the UK

The Royal College of Anaesthetists, the Royal College of Physicians, the Intensive Care Society and the Resuscitation Council (UK) have published new resuscitation standards. The document provides advice to UK healthcare organisations, resuscitation committees and resuscitation officers on all aspects of the resuscitation service. It includes sections on resuscitation training, resuscitation equipment, the cardiac arrest team, cardiac arrest prevention, patient transfer, post resuscitation care, audit and research. The document makes several recommendations. Healthcare institutions should have, or be represented on, a resuscitation committee that is responsible for all resuscitation issues. Every institution should have at least one resuscitation officer responsible for teaching and conducting training in resuscitation techniques. Staff with patient contact should be given regular resuscitation training appropriate to their expected abilities and roles. Clinical staff should receive regular training in the recognition of patients at risk of cardiopulmonary arrest and the measures required for the prevention of cardiopulmonary arrest. Healthcare institutions admitting acutely ill patients should have a resuscitation team, or its equivalent, available at all times. Clear guidelines should be available indicating how and when to call for the resuscitation team. Cardiopulmonary arrest should be managed according to current national guidelines. Resuscitation equipment should be available throughout the institution for clinical use and for training. The practice of resuscitation should be audited to maintain and improve standards of care. A do not attempt resuscitation (DNAR) policy should be compiled, communicated to relevant members of staff, used and audited regularly. Funding must be provided to support an effective resuscitation service.

Long-term outcome of paediatric cardiorespiratory arrest in Spain

OBJECTIVE

To analyse the final outcome of cardiorespiratory arrest (CRA) in children and the neurological and functional state of survivors at 1 year.

METHODS

An 18-month prospective, multicentre study analysing out-of-hospital and in-hospital CRA in children was carried out; 283 children between 7 days and 17 years of age were included. CRA and resuscitation data were registered according to Utstein style. The outcome variables were: sustained return of spontaneous circulation (initial survival), and survival at 1 year (final survival). The status of survivors was evaluated by means of the paediatric cerebral performance category (PCPC) scale and the paediatric overall performance category (POPC) scale at Paediatric Intensive Care Unit discharge, at hospital discharge, and at 1 year follow-up.

RESULTS

In 283 children, 311 CRA episodes, 73 respiratory arrests (23.5%) and 238 cardiac arrests (76.5%) were analysed. Seventeen children suffered more than one CRA episode (range: 2-6). The initial survival was 60.2% and 1-year survival was 33.2%. The final survival was significantly higher in respiratory arrest than in cardiac arrest patients (70.0% versus 21.1%) (P < 0.0001). After 1 year follow-up, 87.3% of patients had scores 1 or 2 on the PCPC scale and 84.0% had scores 1 or 2 in the POPC scale; these results indicate that 1 year after CRA, the majority of survivors had normal neurological and functional status or showed only mild disability.

CONCLUSIONS

Prognosis of CRA in children continues to be poor in terms of survival but quite good in terms of neurological and functional status among survivors. Additional strategies and efforts are needed to improve the short-term prognosis of paediatric CRA. However, the long-term outcome of survivors is reassuring.

In-hospital cardiac arrest: survival depends mainly on the effectiveness of the emergency response

OBJECTIVES

To evaluate the factors affecting the outcome of in-hospital cardiac arrest.

SETTING

A 1400-bed tertiary care teaching hospital with a dedicated cardiac arrest team (CAT). The CAT was immediately available in monitored areas (intensive care unit and emergency room). In the wards the staff had only BLS skills and automated external defibrillation was not available.

METHODS

A 2-year prospective audit according to the Utstein style.

RESULTS

A total of 114 cardiac arrests (37 with VF/VT and 77 with non-VF/VT) were included. Fifty-two cardiac arrests (46%) occurred in monitored areas, 62 (54%) occurred in non-monitored areas. The CAT arrival time in non-monitored areas was 3.98+/-1.73 min. Thirty-seven patients (32%) survived to hospital discharge. Cardiac arrests occurring in monitored areas had a significantly better outcome than those occurring in the wards. Patient survival in the wards was significantly higher when the CAT arrival time was less than 3 min. No patient whose CAT arrival time was longer than 6 min survived. CAT arrival time was significantly shorter (1.30+/-1.70) in survivors than in non-survivors (2.51+/-2.37; P<0.005). Sex, age and presence of bystanders were not significantly associated with survival.

CONCLUSIONS

In our setting, where bystander defibrillation was not available, the survival of patients having cardiac arrest in non-monitored areas strongly depends on advanced life support provided by the CAT. A faster CAT response and early defibrillation from the ward staff are the most important improvements necessary to increase cardiac arrest survival in our setting.

Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries

Outcome following cardiac arrest and cardiopulmonary resuscitation is dependent on critical interventions, particularly early defibrillation, effective chest compressions, and advanced life support. Utstein-style definitions and reporting templates have been used extensively in published studies of cardiac arrest, which has led to greater understanding of the elements of resuscitation practice and progress toward international consensus on science and resuscitation guidelines. Despite the development of Utstein templates to standardize research reports of cardiac arrest, international registries have yet to be developed. In April 2002 a task force of ILCOR met in Melbourne, Australia, to review worldwide experience with the Utstein definitions and reporting templates. The task force revised the core reporting template and definitions by consensus. Care was taken to build on previous definitions, changing data elements and operational definitions only on the basis of published data and experience derived from those registries that have used Utstein-style reporting. Attention was focused on decreasing the complexity of the existing templates and addressing logistical difficulties in collecting specific core and supplementary (i.e., essential and desirable) data elements recommended by previous Utstein consensus conference. Inconsistencies in terminology between in-hospital and out-of-hospital Utstein templates were also addressed. The task force produced a reporting tool for essential data that can be used for both quality improvement (registries) and research reports and that should be applicable to both adults and children. The revised and simplified template includes practical and succinct operational definitions. It is anticipated that the revised template will enable better and more accurate completion of all reports of cardiac arrest and resuscitation attempts. Problems with data definition, collection, linkage, confidentiality, management, and registry implementation are acknowledged and potential solutions offered. Uniform collection and tracking of registry data should enable better continuous quality improvement within every hospital, EMS system, and community.

Guidelines for appropriate in-hospital emergency team time management: the Brooke Army Medical Center approach

Successful outcome following cardiac arrest have been reported in the range of 13-59%. It is well established that the time from the onset of a ventricular arrhythmia to successful defibrillation predicts outcome. Recent out of hospital arrest protocols minimizing time to defibrillation have reported significant improvement in outcomes. The Bethesda conference and American Heart Association (AHA) both set standards for defibrillation time for in hospital codes but do not set standards for other interventions. In February 2000, the Brooke Army Medical Center (BAMC) cardiopulmonary resuscitation committee published time guidelines for the initiation of CPR, emergency team arrival, first defibrillation and first medication. We sought to evaluate resuscitation outcomes before and after this intervention.

METHODS

Data on each response time was prospectively collected as was etiology for the event, emergency location, patient age, gender, and emergency outcome for the 7 months prior to the guideline introduction and 15 months afterwards.

RESULTS

The mean response times (in minutes) for initiation of CPR (1.3 vs. 0.4), emergency team arrival (1.6 vs. 1.2), first defibrillation (7.8 vs. 6.6) and first medication (4.1 vs. 3.8) demonstrated trends toward improvement. Compliance with the time standards also increased (67-91, 85-95, 67-71 and 93-86%, respectively). Emergency survival trended toward improvement (47 vs. 57%) while discharge survival significantly increased from 3 to 24% (P=0.017).

CONCLUSIONS

Setting time guidelines for Advanced Cardiac Life Support (ACLS) improved initiation of CPR, emergency team arrival, first defibrillation, and first medication administration. These time reductions were accompanied by improved event survival and a statistically improved survival to discharge.

An evaluation of pediatric in-hospital advanced life support interventions using the pediatric Utstein guidelines: a review of 203 cardiorespiratory arrests

PURPOSE

Evaluate the efficacy of advanced life support interventions using the pediatric Utstein guidelines.

METHODS

Charts from all patients for whom a cardiorespiratory arrest code was called during a six-year period in a university affiliated centre were reviewed. Data were recorded according to the pediatric Utstein guidelines and a P < 0.05 was considered significant.

RESULTS

Of the 234 calls, 203 were retained for analysis. The overall survival rate at one year was 26.0% of which 10% had deterioration of their neurologic status compared to the pre-cardiorespiratory arrest evaluation. Time to achieve sustained return of spontaneous circulation (ROSC; P < 0.0001) and sustained measurable blood pressure (P = 0.002), to perform endotracheal intubation (P = 0.04) and the dose of sodium bicarbonate (P < 0.0001) were indicators of long-term survival. Two patients were alive at one year with unchanged neurologic status despite a time to achieve sustained ROSC longer than 30 min (38 and 44 min). The mean first epinephrine dose of patients for whom ROSC was achieved but unsustained was higher than those for whom ROSC was achieved and sustained (0.038 +/- 0.069 mg*kg(-1) vs 0.011 +/- 0.006 mg*kg(-1); P = 0.004). Survival rate and mean first epinephrine dose of patients who received their first epinephrine dose endotracheally (13.3%; 0.011 +/- 0.004 mg*kg(-1)) were comparable to those of patients who received their first epinephrine dose intravenously (7%; 0.015 +/- 0.027 mg*kg(-1)).

CONCLUSIONS

For intravenously administered epinephrine, a dose of 0.01 mg*kg(-1) seems appropriate as the first dose. The endotracheal route is a valuable alternative for epinephrine administration and, for infants, the dose does not need to be increased. A minimal resuscitation duration time of 30 min can be misleading if ROSC is used as the indicator.

Prevalence of 'do not attempt resuscitation' orders and living wills among patients suffering cardiac arrest in four secondary hospitals

OBJECTIVE

To assess the prevalence and implementation of 'do not resuscitate' orders, nowadays called 'do not attempt resuscitation' (DNAR) orders and living wills among patients suffering in-hospital cardiac arrest (CA) in whom cardiopulmonary resuscitation was not initiated.

MATERIALS AND METHODS

A prospective survey of CA patients conducted in four secondary hospitals during 2000-2001. The information collected included the presence of DNAR and a living will and the patients sociodemographic and disease factors and the reasons for not initiating resuscitation when no DNAR order was present. Data on the resuscitated patients were collected according to the Utstein recommendations (analyzed and published separately) and used for comparison.

RESULTS

During the study period, 1486 patients suffered CA without resuscitation being initiated. Data collection was successful in 1143 patients (77%), who were included in the study. Most of the patients (84.5%) had a DNAR order. The prevalence of DNAR orders differed between the participating hospitals (P<0.001), and between the wards of the hospital, with most DNAR orders in the cardiac care unit (100%) and medical wards (87%). The patients designated as DNAR were likely to be older (P<0.01) and of poorer functional status (P<0.001). Reasons for abstaining from resuscitation without a DNAR order were unwitnessed arrest (27%) and terminal disease (66%). Living wills were uncommon (1.5%). Patients with a living will were likely to have a DNAR order (P<0.01).

CONCLUSION

Most patients who suffered in-hospital CA without resuscitation had a DNAR order, and, for those who did not, terminal disease and medical futility were evident in most cases. Living wills were uncommon, but they appeared to have had some impact on treatment.

Evaluation of the in-hospital Utstein template in cardiopulmonary resuscitation in secondary hospitals

INTRODUCTION

The in-hospital Utstein template for cardiopulmonary resuscitation (CPR) was assessed in four secondary hospitals (334-441 beds) which did not have systematic data collection.

MATERIALS AND METHODS

The reports and outcome over a period of 12 months during the years 2000-2001 were evaluated.

RESULTS

Of a total of 1690 patients that had a cardiac arrest (CA), 204 (12%) were resuscitated. Information on the collected Utstein parameters were available as follows: initial rhythm in 91%, time interval from collapse to defibrillation (in case of ventricular fibrillation or ventricular tachycardia as initial rhythm) in 90%, time interval to return of spontaneous circulation (ROSC) in 83% and duration of resuscitation in 83%. ROSC was achieved in 69 patients (34%, CI 27-41%) and 34 (17%, CI 11-23%) survived to hospital discharge. Twenty patients showed satisfactory neurological recovery (10%, CI 6-14%). Eighteen (9%, CI 5-13%) patients were alive at 12 months from the event. Factors associated with survival to hospital discharge were VF/VT (P=0.007) as the initial rhythm and shorter interval to defibrillation (P=0.046).

CONCLUSION

The in-hospital Utstein template was logical but laborious and it provided tools for resuscitation management evaluation in the study hospitals. For continuous use, a slightly compressed model may be warranted. In the present material, the overall survival rate to hospital discharge was in line with previous reports but there were somewhat less neurologically satisfactory survivors. There is an evident need to improve the outcome of patients suffering CA on the wards. An important step is to reduce the time interval to defibrillation.

A survey of the in-hospital response to cardiac arrest on general wards in the hospitals of Rome

OBJECTIVE

To investigate the response to cardiac arrest in general wards.

METHODS

Direct interview with the cardiac arrest team (CAT) members in 32 hospitals in Rome, Italy.

RESULTS

The majority of CATs are activated by telephone but only two (6%) hospitals have a dedicated telephone number for emergency calls. The CAT always includes a physician, who is usually an anaesthesiologist (30 hospitals, 94%), and usually includes one or two other members (23 hospitals, 72%). In 21 hospitals (65%) there is less than one defibrillator per floor but in only six hospitals (19%), CATs are equipped with defibrillators. Resuscitation guidelines are adopted by 15 teams (47%). The Utstein style of data collection is used in only one hospital. The most common problems reported by the CATs are: insufficient training of ward personnel (29 hospitals, 91%), insufficient staff (19 hospitals, 59%) and insufficient equipment (18 hospitals, 56%). Average maximum arrival time for the CAT to arrive is 220 s, but varies significantly between single-building and the multiple-building hospitals (88 vs. 390 s; P<0.001).

CONCLUSIONS

The majority of the cardiac arrest teams have acceptable response times, but their efficiency may be impaired by the lack of staff, equipment and co-ordination with the ward personnel. CAT members identified a strong need for BLS training of ward personnel. More widespread introduction of standard protocols for resuscitation and reporting of cardiac arrest are necessary to evaluate aspects that may need improvement.

In-hospital cardiac arrest: what happens to the false arrests?

OBJECTIVE

To investigate the events surrounding false cardiac arrest calls and subsequent outcome in patients who were the subjects of such calls.

METHODS

A retrospective review of the cardiac arrest audit database pertaining to all false cardiac arrest calls logged by the hospital telephone switchboard at a London Teaching Hospital over a 22-month period.

RESULTS

There were 59 false cardiac arrest calls. Of these 30 calls were immediately rescinded and 29 calls were erroneous. An abnormality of heart rhythm was the commonest cause for an erroneous call. Other important causes included epileptic seizure and hypovolaemia secondary to blood loss (whether due to medical or surgical causes). Three patients who were the subject of a rescinded call and 4 patients who were the subject of an erroneous call died in hospital without going home. Life table analysis revealed that for every 10 false arrests, eight patients were alive at 24 h, six patients were alive at 6 weeks, four patients were alive at 6 months and three patients were alive at 1 year.

CONCLUSIONS

There is a need for a wider appreciation of the significance of false cardiac arrest calls.

In-hospital cardiopulmonary resuscitation: organization, management and training in hospitals of different levels of care

BACKGROUND

: During recent years in-hospital cardiopulmonary resuscitation (CPR) management has received much attention. This can be attributed to the Utstein model for in-hospital CPR developed in 1997. The present status of in-hospital resuscitation management in Finnish hospitals is not known. Therefore, a study was designed to describe the organization of training and clinical management of CPR in Finnish hospitals of different levels of care.

METHODS

: In the summer of 2000, we performed a cross-sectional mail survey throughout Finland, including all district, central and university hospitals. The questionnaire outlined in detail in-hospital resuscitation management and training. For analysis the hospitals were divided into primary, secondary and tertiary groups, depending on levels of care.

RESULTS

: Most hospitals (72%) reported having a physician or a nurse in charge of resuscitation management and training. Training in advanced life support was more common among nurses (80%) than among physicians (53%). Surprisingly, a majority of respondents (75%) reported that they felt training in CPR was insufficient. On the general wards and on wards treating cardiac patients, defibrillation was in most cases performed by a physician (91% and 51%, respectively), and less often by a nurse (16% and 31%, respectively). In the secondary and tertiary hospitals cardiac arrest was managed by a cardiac arrest team (53% and 62%, respectively) and in the primary hospitals by the ward physician (56%), anesthesiologist or emergency physician on call (44%). Most hospitals used do-not-resuscitate orders (83%) but only 33% of the hospitals had a unified style of notation. Systematic data collection was practised in 55% of hospitals, predominantly by using a model of their own. Only a few hospitals (11%) used the in-hospital Utstein model.

CONCLUSION

: Our study showed that more attention needs to be paid to CPR management in Finnish hospitals. At present, 25% of hospitals do not have an appointed physician or nurse in charge of organizing CPR management. The study also revealed a lack of regular organized training in resuscitation for physicians. Fifty-five per cent of hospitals practise systematic data collection, but only 11% according to the Utstein template; and without which further quality assurance is difficult.