Long-term functional recovery and health-related quality of life of elderly out-of-hospital cardiac arrest survivors

No healthcare coverage, big problem: lack of insurance for older population associated with worse emergency general surgery outcomes

Introduction

Older populations, being a unique subset of patients, have poor outcomes for emergency general surgery (EGS). In regions lacking specialized medical coverage for older patients, disparities in healthcare provision lead to poor clinical outcomes. We aimed to identify factors predicting index admission inpatient mortality from EGS among sexagenarians, septuagenarians, and octogenarians.

Methods

Data of patients aged >60 years with EGS conditions defined by the American Association for the Surgery of Trauma at primary index admission from 2010 to 2019 operated and non-operated at a large South Asian tertiary care hospital were analyzed. The primary outcome was primary index admission inpatient 30-day mortality. Parametric survival regression using Weibull distribution was performed. Factors such as patients' insurance status and surgical intervention were assessed using adjusted HR and 95% CI with a p-value of <0.05 considered statistically significant.

Results

We included 9551 primary index admissions of patients diagnosed with the nine most common primary EGS conditions. The mean patient age was 69.55±7.59 years. Overall mortality and complication rates were 3.94% and 42.29%, respectively. Primary index admission inpatient mortality was associated with complications including cardiac arrest and septic shock. Multivariable survival analysis showed that insurance status was not associated with mortality (HR 1.13; 95% CI 0.79, 1.61) after adjusting for other variables. The odds of developing complications among self-paid individuals were higher (adjusted OR 1.17; 95% CI 1.02, 1.35).

Conclusion

Lack of healthcare coverage for older adults can result in delayed presentation, leading to increased morbidity. Close attention should be paid to such patients for timely provision of treatment. There is a need to expand primary care access and proper management of comorbidities for overall patient well-being. Government initiatives for expanding insurance coverage for older population can further enhance their healthcare access, mitigating the risk of essential treatments being withheld due to financial limitations.

Level of evidence

III.

Increasing neurologically intact survival after out-of-hospital cardiac arrest among elderly: Singapore Experience

Objectives

With more elderly presenting with Out-of-Hospital Cardiac Arrests (OHCAs) globally, neurologically intact survival (NIS) should be the aim of resuscitation. We aimed to study the trend of OHCA amongst elderly in a large Asian registry to identify if age is independently associated with NIS and factors associated with NIS.

Methods

All adult OHCAs aged ≥18 years attended by emergency medical services (EMS) from April 2010 to December 2019 in Singapore was extracted from the Pan-Asian Resuscitation Outcomes Study (PAROS) registry. Cases pronounced dead at scene, non-EMS transported, traumatic OHCAs and OHCAs in ambulances were excluded. Patient characteristics and outcomes were compared across four age categories (18-64, 65-79, 80-89, ≥90). Multivariable logistic regression analysis determined the factors associated with NIS.

Results

19,519 eligible cases were analyzed. OHCA incidence increased with age almost doubling in octogenarians (from 312/100,000 in 2011 to 652/100,000 in 2019) and tripling in those ≥90 years (from 458/100,000 in 2011 to 1271/100,000 in 2019). The proportion of patients with NIS improved over time for the 18-64, 65-79- and 80-89-years age groups, with the greatest improvement in the youngest group. NIS decreased with each increasing year of age and minute of response time. NIS increased in the arrests of presumed cardiac etiology, witnessed and bystander CPR.

Conclusions

Survival with good outcomes has increased even amongst the elderly. Regardless of age, NIS is possible with good-quality CPR, highlighting its importance. End-of-life planning is a complex yet necessary decision that requires qualitative exploration with elderly, their families and care providers.

How do survivors after out-of-hospital cardiac arrest perceive their health compared to the norm population? A nationwide registry study from Norway

Introduction

Self-perceived health status data is usually collected using patient-reported outcome measures. Information from the patients' perspective is one of the important components in planning person-centred care. The study aimed to compare EQ-5D-5L in survivors after out-of-hospital cardiac arrest (OHCA) with data for Norwegian population controls. Secondary aim included comparing characteristics of respondents and non-respondents from the OHCA population.

Methods

In this cross-sectional survey, 714 OHCA survivors received an electronic EQ-5D-5L questionnaire 3-6 months following OHCA. EQ-5D-5L assesses for five dimensions of health (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) with five-point descriptive scales and overall health on a visual analogue scale from 0 (worst) to 100 (best) (EQ VAS). Results are used to calculate the EQ index ranging from -0.59 (worst) to 1 (best). Patient responses were matched for age and sex with existing data from controls, collected through a postal survey (response rate 26%), and compared with Chi-square tests or t-tests as appropriate.

Results

Of 784 OHCA survivors, 714 received the EQ-5D-5L, and 445 (62%) responded. Respondents had higher rates of shockable first rhythm and better cerebral performance category scores than the non-respondents. OHCA survivors reported poorer health compared to controls as assessed by EQ-5D-5L dimensions, the EQ index (0.76 ± 0.24 vs 0.82 ± 0.18), and EQ VAS (69 ± 21 vs 79 ± 17), except for the pain/discomfort dimension.

Conclusions

Norwegian OHCA survivors reported poorer health than the general population as assessed by the EQ-5D-5L. PROMs use in this population can be used to inform follow-up and health care delivery.

Frequency of resuscitation attempts with dying nursing home residents. A full survey in an urban district in Germany based on registry data from 2018-2021

Aim

The realities of emergency care and resuscitation research involving nursing home (NH) residents suggest an overuse of resuscitation attempts in NHs. A complete analysis of all NH resident deaths is needed to provide a complementary perspective of potential underuse. The present research investigated whether residents of different NH homes died at the NH during attempted resuscitation or after transfer to hospital.

Methods

A full survey of resuscitation attempts and deaths among NH residents, via retrospective analysis of data from the death registry and the German Resuscitation Registry for the years 2018 to 2021.

Results

Over the 4-year study period, 14,598 individuals died, of whom 3,288 (22.5%) were residents of 31 different NHs. The mean age of the deceased NH residents was 87 years (±8.6); 2,196 (66.8%) were female, 118 (3.6%) underwent a resuscitation attempt, and 58.5% died at the NH. NH averages were as follows: deaths per NH: 106 (±51; min-max: 36-292); number of beds: 102 (±39; 34-210); deaths per bed per year 0.27 (±0.07; 0.15-0.51); resuscitation attempts per 1,000 beds per year: 9.5 (±5.5; 0-21.1); and ratio of futile resuscitation attempts to deaths: 6.0% (0-12.5%). Considering the entire study region before and during the COVID-19 pandemic, a slight underuse of resuscitation attempts with female NH residents emerged. On a facility level, substantial disparities and opposing trends were found. The incidence of deaths and resuscitation attempts, as well as the place of death and the ratio of futile resuscitation attempts to deaths, varied considerably.

Conclusion

Resuscitation attempts are rarely administered to dying NH residents. However, their frequency varies considerably between NHs.

Out-of-hospital cardiac arrest in residential aged care facilities is independently associated with lower survival in Perth, Australia

Aim

To compare out-of-hospital cardiac arrest (OHCA) characteristics and outcomes between people aged ≥ 65 years who arrested in a residential aged care facility (RACF) versus a private residence in Perth, Australia.

Methods

We undertook a retrospective cohort study of OHCA cases attended by emergency medical services (EMS) in Perth, January 2018-December 2021. OHCA patient and event characteristics and survival outcomes were compared via univariate analysis. Multivariable logistic regression was used to investigate the relationship between residency type and (i) return of spontaneous circulation (ROSC) at emergency department (ED) and (ii) 30-day survival.

Results

A total of 435 OHCA occurred in RACFs versus 3,395 in private residences. RACF patients were significantly older (median age: 86 [IQR 79, 91] vs 78 [71, 85] years; p < 0.001), more commonly female (50.1% vs 36.8%; p < 0.001), bystander-witnessed arrests (34.9% vs 21.5%; p < 0.001), received bystander cardiopulmonary resuscitation (42.1% vs 28.6%; p < 0.001), had less shockable first monitored rhythms (4.0% vs 8.1%; p = 0.002) and more frequently had a "do not resuscitate" order identified (46.0% vs 13.6%; <0.001). Among those with EMS-attempted resuscitation or with defibrillation before EMS arrival, ROSC at ED and 30-day survival were significantly lower in the RACF group (6.2% vs 18.9%; p < 0.001 and 1.9% vs 7.7%; p < 0.001). The adjusted odds of ROSC at ED (aOR: 0.22 [95%CI: 0.10, 0.46]) and 30-day survival (aOR: 0.20 [95%CI 0.05, 0.92]) were significantly lower for RACF residents.

Conclusion

RACF residency was an independent predictor of lower survival from OHCA, highlighting the importance of end-of-life planning for RACF residents.

A two-point strategy to clarify prognosis in >80 year olds experiencing out of hospital cardiac arrest

BACKGROUND

The global population is aging, with the number of ≥80-year-olds projected to triple over the next 30 years. Rates of out-of-hospital cardiac arrest (OHCA) are also increasing within this age group.

METHODS

The Victorian Ambulance Cardiac Arrest Registry was utilised to identify OHCAs in patients aged ≥80 years between 2002-2021. Predictors of survival to discharge were defined and a prognostic score derived from this cohort.

RESULTS

77,628 patients experienced OHCA of whom 25,269 (32.6%) were ≥80 years (80-90 years = 18,956; 90-100 years = 6,148; >100 years = 209). The number of patients ≥80 years increased over time both absolutely (p = 0.002) and proportionally (p = 0.028). 619 (2.4%) patients survived to discharge without change over time. Older ages had no difference in witnessed OHCA status but were less likely to have shockable rhythm (OR 0.50 (95% CI 0.44-0.57) for 90-100-year-olds, OR 0.28 (95% CI 0.12-0.63) for 90-100-year-olds). If OHCA was witnessed and there was a shockable rhythm then survival was 14%; if one factor was present survival was 5-6% and if neither factor was present, survival was 0.09%. These survival rates enabled derivation of a simplified prognostic assessment score - the '15/5/0' score - highly comparable to a previously-published American cohort.

CONCLUSIONS

Elderly OHCA rates have increased to one-third of caseload. The most important factors predicting survival were whether the OHCA was witnessed and there was a shockable rhythm. We present a simple two-point '15/5/0' prognostic score defining which patients will gain most from advanced resuscitative measures.

Resuscitation of older adults in Norway; a comparison of survival and outcome after out-of-hospital cardiac arrest in healthcare institutions and at home

BACKGROUND

Perceptions about expected outcome after out-of-hospital cardiac arrest (OHCA) influence treatment decisions, and there is a need for updated evidence about outcomes for the elderly.

METHOD

We conducted a cross-sectional study of cases reported to the Norwegian Cardiac Arrest Registry from 2015 through 2021 of patients 60 years and older, suffering cardiac arrest in healthcare institutions or at home. We examined reasons for emergency medical service (EMS) withholding or withdrawing resuscitation. We compared survival and neurological outcome for EMS-treated patients and explored factors associated with survival using multivariate logistic regression.

RESULT

We included 12,191 cases and the EMS started resuscitation in 10,340 (85%). The incidence per capita of OHCA the EMS were alerted to was 267/100,000 in healthcare institutions and 134/100,000 at home. Resuscitation was most frequently withdrawn due to medical history (n = 1251). In healthcare institutions, 72 of 1503 (4.8%) patients survived to 30 days compared to 752 of 8837 (8.5%) at home (P <.001). We found survivors in all age cohorts both in healthcare institutions and at home, and most of the 824 survivors had a good neurological outcome with a Cerebral Performance Category ≤2 (88%).

CONCLUSION

Medical history was the most frequent reason for EMS not to start or continue resuscitation, indicating a need for a discussion about, and documentation of, advance directives in this age group. When EMS attempted resuscitation, most survivors had a good neurological outcome, both in healthcare institutions and at home.

Determinants of health-related quality of life after out-of-hospital cardiac arrest (OHCA): A systematic review

OBJECTIVE

With a growing number of out-of-hospital cardiac arrest (OHCA) survivors globally, the focus of OHCA management has now broadened to survivorship. An outcome central to survivorship is health-related quality of life (HRQoL). This systematic review aimed to synthesise evidence related to the determinants of HRQoL of OHCA survivors.

METHODS

We systematically searched MEDLINE, Embase, and Scopus from inception to 15 August 2022 to identify studies investigating the association of at least one determinant and HRQoL in adult OHCA survivors. All articles were independently reviewed by two investigators. We abstracted data pertaining to determinants and classified them using a well-established HRQoL theoretical framework - the Wilson and Cleary (revised) model.

RESULTS

31 articles assessing a total of 35 determinants were included. Determinants were classified into the five domains in the HRQoL model. 26 studies assessed determinants related to individual characteristics (n=3), 12 studied biological function (n=7), nine studied symptoms (n=3), 16 studied functioning (n=5), and 35 studied characteristics of the environment (n=17). In studies that included multivariable analyses, most reported that individual characteristics (older age, female sex), symptoms (anxiety, depression), and functioning (impaired neurocognitive function) were significantly associated with poorer HRQoL.

CONCLUSIONS

Individual characteristics, symptoms, and functioning played significant roles in explaining the variability in HRQoL. Significant non-modifiable determinants such as age and sex could be used to identify populations at risk of poorer HRQoL, while significant modifiable determinants such as psychological health and neurocognitive functioning could serve as targets for post-discharge screening and rehabilitation plans. PROSPERO registration number: CRD42022359303.

Targeted temperature management on outcome of older adult patients after out-of-hospital cardiac arrest

BACKGROUND

Targeted temperature management (TTM) can potentially improve the prognosis of patients with out-of-hospital cardiac arrest (OHCA). However, the effectiveness of TTM in older adults remains unknown. Therefore, this study aimed to assess the outcomes of older adult patients with OHCA who underwent TTM.

METHODS

This study was a multicenter, retrospective, nationwide observational analysis of the Japanese Association for Acute Medicine out-of-hospital cardiac arrest (JAAM-OHCA) registry. We included patients aged ≥18 years who had experienced OHCA and underwent TTM from June 1, 2014, to December 31, 2017, in Japan. The primary outcome was a 1-month neurological favorable outcome, and the secondary outcome was 1-month survival.

RESULTS

A total of 1847 patients were included in the analysis. 79 of 389 patients aged ≥75 years (20.3%) had a 1-month neurological favorable outcome compared with 369 of 959 patients aged 18-64 years (38.5%) (adjusted odds ratios, 0.31; 95% confidence interval [CI], 0.21-0.45; P for trend <0.001). With increasing age, 1-month mortality showed an increasing trend; however, there was no significant difference.

CONCLUSION

In this retrospective nationwide observational study in Japan, neurological outcomes worsened as age increased in patients with OHCA who underwent TTM.

Transferring nursing home residents to emergency departments by emergency physician-staffed emergency medical services: missed opportunities to avoid inappropriate care?

BACKGROUND

The decision to transfer a nursing home (NH) resident to an emergency department (ED) is multifactorial and challenging but many of the emergency physician-staffed emergency medical service (EP-EMS) interventions and ED transfers are probably inappropriate.

METHODS

We conducted a retrospective, cross-sectional study in three EP-EMSs in Belgium over a period of three years. We registered indicators that are potentially associated with inappropriate transfers: patient characteristics, availability of written do not resuscitate (DNR) orders or treatment restrictions, involvement of a general practitioner (GP) and availability of transfer notes. We also explored the association between age, the Charlson Comordity Index (CCI), polypharmacy, dementia, and the availability of DNR documents.

RESULTS

We registered 308 EP-EMS interventions in NH residents. In 98% the caller was a health-care professional. In 75% there was no GP present and 40% had no transfer note. Thirty-two percentage of the patients had dementia, 45% had more than two comorbidities and 68% took five medications or more. In 6% cardiopulmonary resuscitation was performed. DNR orders were available in 25%. Eighty-eight percentage of the NH residents were transferred to the ED. Forty-four percent had a CCI >5. In patients of ≥90 years, with a CCI >5, with dementia and with polypharmacy, DNR orders were not available in 81%, 67%%,and 69%, respectively.

CONCLUSIONS

Improved EMS dispatch centre-NH caller interaction, more involvement of GP's, higher availability of DNR orders and better communication between GPs/NHs and EP-EMS could prevent inappropriate interventions, futile prehospital aactions,and ED transfers.

Cost-minimization analysis of a wearable cardioverter defibrillator in adult patients undergoing ICD explant procedures: Clinical and economic implications

Aims

Patients with permanently increased risk of sudden cardiac death (SCD) can be protected by implantable cardioverter defibrillators (ICD). If an ICD must be removed due to infection, for example, immediate reimplantation might not be possible or indicated. The wearable cardioverter defibrillator (WCD) is an established, safe and effective solution to protect patients from SCD during this high‐risk bridging period. Very few economic evaluations on WCD use are currently available.

Methods

We conducted a systematic review to evaluate the available evidence of WCD in patients undergoing ICD explant/lead extraction. Additionally, a decision model was developed to compare use and costs of the WCD with standard therapy (in‐hospital stay). For this purpose, a cost‐minimization analysis was conducted, and complemented by a one‐way sensitivity analysis.

Results

In the base case scenario, the WCD was less expensive compared to standard therapy. The cost‐minimization analysis showed a cost reduction of €1782 per patient using the WCD. If costs of standard care were changed, cost savings associated with the WCD varied from €3500 to €0, assuming costs for standard care of €6800 to €3600.

Conclusion

After ICD explantation, patients can be safely and effectively protected from SCD after hospital discharge through WCD utilization. Furthermore, the use of a WCD for this patient group is cost saving when compared to standard therapy.

Intensive care-treated cardiac arrest: a retrospective study on the impact of extended age on mortality, neurological outcome, received treatments and healthcare-associated costs

Background

Cardiac arrest (CA) is a leading cause of death worldwide. As population ages, the need for research focusing on CA in elderly increases. This study investigated treatment intensity, 12-month neurological outcome, mortality and healthcare-associated costs for patients aged over 75 years treated for CA in an intensive care unit (ICU) of a tertiary hospital.

Methods

This single-centre retrospective study included adult CA patients treated in a Finnish tertiary hospital’s ICU between 2005 and 2013. We stratified the study population into two age groups: <75 and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥75 years. We compared interventions defined by the median daily therapeutic scoring system (TISS-76) between the age groups to find differences in treatment intensity. We calculated cost-effectiveness by dividing the total one-year healthcare-associated costs of all patients by the number of survivors with a favourable neurological outcome. Favourable outcome was defined as a cerebral performance category (CPC) of 1–2 at 12 months after cardiac arrest. Logistic regression analysis was used to identify independent associations between age group, mortality and neurological outcome.

Results

This study included a total of 1,285 patients, of which 212 (16 %) were \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥75 years of age. Treatment intensity was lower for the elderly compared to the younger group, with median TISS scores of 116 and 147, respectively (p < 0.001). The effective cost in euros for patients with a good one-year neurological outcome was €168,000 for the elderly and €120,000 for the younger group. At 12 months after CA 24 % of the patients in the elderly group and 47 % of the patients in the younger group had a CPC of 1–2 (p < 0.001). Age was an independent predictor of mortality (multivariate OR = 2.90, 95 % CI: 1.94–4.31, p < 0.001) and neurological outcome (multivariate OR = 3.15, 95 % CI: 2.04–4.86, p < 0.001).

Conclusions

The elderly ICU-treated CA patients in this study had worse neurological outcomes, higher mortality and lower cost-effectiveness than younger patients. Elderly received less intense treatment. Further efforts are needed to recognize the tools for assessing which elderly patients benefit from a more aggressive treatment approach in order to improve the cost-effectiveness of post-CA management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00923-0.

[Ethics of resuscitation and end of life decisions]

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

The outcome of in- and out-hospital cardiopulmonary arrest in the older population: a scoping review

Aim

We aimed to collect the available evidence on outcome regarding survival and quality of life after CPR following both IHCA and OHCA in the older population.

Findings

Hospital survival rates following IHCA and OHCA in the older population improved in the recent decade, though do not exceed 28.5% and 11.1%, respectively. The effect of age on outcome remains controversial and age should not be used as the sole decision criterium whether to initiate CPR.

Message

Future research should study frailty and resilience as an independent predictor regardless of age, and add broader, extensive QoL measures as outcome variables.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00454-y.

Purpose

We aimed to collect the available evidence on outcome regarding survival and quality of life after cardiopulmonary resuscitation (CPR) following both in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) in the older population.

Methods

A scoping review was performed studying published reviews after 2008, focusing on outcome of CPR in patients aged ≥ 70 years following IHCA and OHCA. In addition, 11 (IHCA) and 19 (OHCA) eligible studies published after the 2 included reviews were analyzed regarding: return of spontaneous circulation, survival until hospital discharge, long-term survival, neurological outcome, discharge location or other measurements for quality of life (QoL).

Results

The survival until hospital discharge ranged between 11.6 and 28.5% for IHCA and 0–11.1% for OHCA, and declined with increasing age. The same trend was seen regarding 1-year survival rates with 5.7–25.0% and 0–10% following IHCA and OHCA, respectively. A good neurological outcome defined as a Cerebral Performance Category (CPC) 1–2 was found in 11.5–23.6% (IHCA) and up to 10.5% (OHCA) of all patients. However, the proportion of CPC 1–2 among patients surviving until hospital discharge was 82–93% (IHCA) and 77–91.6% (OHCA). Few studies included other QoL measures as an outcome variable. Other risk factors aside from age were identified, including nursing home residency, comorbidity, non-shockable rhythm, non-witnessed arrest. The level of frailty was not studied as a predictor of arrest outcome in the included studies.

Conclusions

Hospital survival rates following IHCA and OHCA in the older population improved in the recent decade, though do not exceed 28.5% and 11.1%, respectively. The effect of age on outcome remains controversial and age should not be used as the sole decision criterium whether to initiate CPR. Future research should study frailty and resilience as an independent predictor regardless of age, and add broader, extensive QoL measures as outcome variables.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00454-y.

Current trends and outcomes of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Japan: A nationwide observational study

AIM

The present study aimed to describe the prevalence, prognosis and annual trends of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) patients, using a nationwide inpatient database in Japan.

METHODS

This was a nationwide retrospective cohort study, using the Japanese Diagnosis Procedure Combination inpatient database. We included OHCA patients registered in the database from July 2010 to March 2017 and analyzed the annual prevalence of OHCA patients who received ECPR. The outcomes included survival to hospital discharge and survival with favorable neurologic outcome at hospital discharge. The annual trends on the outcomes were also analyzed.

RESULTS

We identified 217,907 eligible patients. OHCA patients were divided into patients with ECPR (n = 5,612) and conventional CPR (n = 212,295). The prevalence of ECPR performed in OHCA patients was 2.6%. ECPR prevalence significantly increased from 2.1% in 2010 to 3.0% in 2016 (P < 0.001). Overall survival to hospital discharge was 16.4% and 2.7% in patients with ECPR and conventional CPR, respectively. Prevalence of patients who were discharged from hospital with favorable neurologic outcome was 12.4% and 1.6% in those with ECPR and conventional CPR, respectively.Increasing age was associated with progressively deteriorating outcomes. The trend of survival to hospital discharge significantly increased on an annual basis.

CONCLUSIONS

The annual prevalence of ECPR significantly increased from 2010 to 2016. Improvements in overall survival to hospital discharge were noted for ECPR in OHCA patients and there was a trend in the tendency for ECPR patients discharged from the hospital to have favorable neurologic outcomes.

Impact of perceived inappropiate cardiopulmonary resuscitation on emergency clinicians' intention to leave the job: Results from a cross-sectional survey in 288 centres across 24 countries

INTRODUCTION

Cardiopulmonary resuscitation (CPR) in patients with a poor prognosis increases the risk of perception of inappropriate care leading to moral distress in clinicians. We evaluated whether perception of inappropriate CPR is associated with intention to leave the job among emergency clinicians.

METHODS

A cross-sectional multi-centre survey was conducted in 24 countries. Factors associated with intention to leave the job were analysed by conditional logistic regression models. Results are expressed as odds ratios with 95% confidence intervals.

RESULTS

Of 5099 surveyed emergency clinicians, 1836 (36.0%) were physicians, 1313 (25.7%) nurses, 1950 (38.2%) emergency medical technicians. Intention to leave the job was expressed by 1721 (33.8%) clinicians, 3403 (66.7%) often wondered about the appropriateness of a resuscitation attempt, 2955 (58.0%) reported moral distress caused by inappropriate CPR. After adjustment for other covariates, the risk of intention to leave the job was higher in clinicians often wondering about the appropriateness of a resuscitation attempt (1.43 [1.23-1.67]), experiencing associated moral distress (1.44 [1.24-1.66]) and who were between 30-44 years old (1.53 [1.21-1.92] compared to <30 years). The risk was lower when the clinician felt valued by the team (0.53 [0.42-0.66]), when the team leader acknowledged the efforts delivered by the team (0.61 [0.49-0.75]) and in teams that took time for debriefing (0.70 [0.60-0.80]).

CONCLUSION

Resuscitation attempts perceived as inappropriate by clinicians, and the accompanying moral distress, were associated with an increased likelihood of intention to leave the job. Interprofessional collaboration, teamwork, and regular interdisciplinary debriefing were associated with a lower risk of intention to leave the job. ClinicalTrials.gov; No.: NCT02356029.

Opportunities and Risks of Resuscitation Attempts in Nursing Homes

BACKGROUND

Data supporting decision-making regarding cardiopulmonary resuscitation (CPR) in German nursing homes is insufficient.

METHODS

A retrospective evaluation of pre-hospital CPR was carried out with data from the German Resuscitation Registry (Deutsches Reanimationsregister) for the years 2011-2018. Patients under age 65 were excluded, as were patients from districts in which long-term data was available for less than 60% of patients. Subgroups were analyzed based on age and certain prehospital situations; patients treated outside nursing homes were used for comparison.

RESULTS

The study group consisted of 2900 patients, whose mean age was 83.7 years (standard deviation, 7.5 years). 1766 (60.9%) were women and 1134 (39.1%) were men. 118 patients (4.0%) were discharged alive, including 64 (2.2%) with a cerebral performance category (CPC) of 1 or 2, 30 (1.0%) with an unknown CPC, and 24 (0.8%) with a CPC of 3 or 4. 902 patients (31.1%) died in the hospital, including five (0.2%) who died more than 30 days after resuscitation, 279 (9.6%) between 24 hours and 30 days, and 618 (21.3%) within 24 hours. 1880 patients (64.8%) died at the site of attempted resuscitation. In 1056 cases (36.4%), CPR was initiated before the arrival of the emergency medical services. In the "initially shockable" subgroup, 13 of 208 patients (6.3%) were discharged alive with a CPC of 1 or 2.

CONCLUSION

CPR can lead to a good neurological outcome in rare cases even when carried out in a nursing home. The large percentage of CPR attempts that were initiated only after a delay indicates that nursing home staff may often be uncertain how to proceed. Uncertainty among caregivers points to a potential for advance care planning.

The role of age in post-cardiac arrest therapy in an elderly patient population

Aim

We investigated the effect of age on post-cardiac arrest treatment outcomes in an elderly population, based on a local database and a systemic review of the literature.

Methods

Data were collected retrospectively from medical charts and reports. Sixty-one comatose patients, cooled to 32-34 °C for 24 h, were categorized into three groups: younger group (≤65 years), older group (66-75 years), and very old group (>75 years). Circumstances of cardiopulmonary resuscitation (CPR), patients' characteristics, post-resuscitation treatment, hemodynamic monitoring, neurologic outcome and survival were compared across age groups. Kruskal-Wallis test, Chi-square test and binary logistic regression (BLR) were applied. In addition, a literature search of PubMed/Medline database was performed to provide a background.

Results

Age was significantly associated with having a cardiac arrest on a monitor and a history of hypertension. No association was found between age and survival or neurologic outcome. Age did not affect hemodynamic parameter changes during target temperature management (TTM), except mean arterial pressure (MAP). Need of catecholamine administration was the highest among very old patients. During the literature review, seven papers were identified. Most studies had a retrospective design and investigated interventions and outcome, but lacked unified age categorization. All studies reported worse survival in the elderly, although old survivors showed a favorable neurologic outcome in most of the cases.

Conclusion

There is no evidence to support the limitation of post-cardiac arrest therapy in the aging population. Furthermore, additional prospective studies are needed to investigate the characteristics and outcome of post-cardiac arrest therapy in this patient group.

Cardiopulmonary Resuscitation in Adults Over 80: Outcome and the Perception of Appropriateness by Clinicians

OBJECTIVES

To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out-of-hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome.

DESIGN

Subanalysis of an international multicenter cross-sectional survey (REAPPROPRIATE).

SETTING

Out-of-hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older.

PARTICIPANTS

A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics.

RESULTS AND MEASUREMENTS

The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the "appropriate" subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the "uncertain" subgroup, and 2 of 107 (1.9%) in the "inappropriate" subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non-shockable rhythms. CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non-shockable rhythms. Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate.

CONCLUSION

Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts. J Am Geriatr Soc 68:39-45, 2019.

Long-term outcome of elderly out-of-hospital cardiac arrest survivors as compared with their younger counterparts and the general population

BACKGROUND:

Over the past decade, prehospital and in-hospital treatment for out-of-hospital cardiac arrest (OHCA) has improved considerably. There are sparse data on the long-term outcome, especially in elderly patients. We studied whether elderly patients benefit to the same extent compared with younger patients and at long-term follow up as compared with the general population.

METHODS:

Between 2001 and 2010, data from all patients presented to our hospital after OHCA were recorded. Elderly patients (⩾75 years) were compared with younger patients. Neurological outcome was classified as cerebral performance category (CPC) at hospital discharge and long-term survival was compared with younger patients and predicted survival rates of the general population.

RESULTS:

Of the 810 patients admitted after OHCA, a total of 551 patients (68%) achieved return of spontaneous circulation, including 125 (23%) elderly patients with a mean age of 81 ± 5 years. In-hospital survival was lower in elderly patients compared with younger patients with rates of 33% versus 57% ( p < 0.001). A CPC of 1 was present in 73% of the elderly patients versus 86% of the younger patients ( p = 0.031). In 7.3% of the elderly patients, a CPC >2 was observed versus 2.5% of their younger counterparts ( p = 0.103). Elderly patients had a median survival of 6.5 [95% confidence interval (CI) 2.0-7.9] years compared with 7.7 (95% CI 7.5-7.9) years of the general population ( p = 0.019).

CONCLUSIONS:

The survival rate after OHCA in elderly patients is approximately half that of younger patients. Elderly patients who survive to discharge frequently have favorable neurological outcomes and a long-term survival that approximates that of the general population.

Assessment of the 11-year nationwide trend of out-of-hospital cardiac arrest cases among elderly patients in Japan (2005-2015)

OBJECTIVE

Japan has one of the most rapidly aging societies worldwide. This study aimed to assess the long-term nationwide trend of out-of-hospital cardiac arrest (OHCA) cases among elderly patients in Japan.

METHODS

This prospective, nationwide observational study in Japan included elderly patients aged ≥65 years who experienced OHCA from January 1, 2005 to December 31, 2015. The patients were classified into three groups: young-old, aged 65-74 years; old-old, aged 75-84 years; and oldest-old, aged ≥85 years. The primary outcome of this study was one-month survival with a favorable neurological outcome, which was defined as a cerebral performance category scale score of 1 or 2.

RESULTS

A total of 877,009 patients were included in our analysis. The number of elderly patients with OHCA increased from 65,968 in 2005 to 87,339 in 2015, and each age category showed a significantly increasing trend (p value <0.001 for each trend). The proportions of favorable neurological outcomes also increased from 1.2% in 2005 to 2.8% in 2015 in the young-old group; from 0.6% in 2005 to 1.1% in 2015 in the old-old group; and from 0.2% in 2005 to 0.5% in 2014 in the oldest-old group. Furthermore, this improving trend was notable for those with a shockable first documented rhythm.

CONCLUSIONS

Based on this long-term nationwide observational study in Japan, the number of elderly patients with OHCA increased annually, and a significant improvement in the patients' neurological outcomes was noted regardless of age category, particularly among those with an initially shockable rhythm.

Ethical challenges in resuscitation

PURPOSE

A rapidly evolving resuscitation science provides more effective treatments to an aging population with multiple comorbidites. Concurrently, emergency care has become patient-centered. This review aims to describe challenges associated with the application of key principles of bioethics in resuscitation and post-resuscitation care; propose actions to address these challenges; and highlight the need for evidence-based ethics and consensus on ethical principles interpretation.

METHODS

Following agreement on the article's outline, subgroups of 2-3 authors provided narrative reviews of ethical issues concerning autonomy and honesty, beneficence/nonmaleficence and dignity, justice, specific practices/circumstances such as family presence during resuscitation, and emergency research. Proposals for addressing ethical challenges were also offered.

RESULTS

Respect for patient autonomy can be realized through honest provision of information, shared decision-making, and advance directives/care planning. Essential prerequisites comprise public and specific healthcare professionals' education, appropriate regulatory provisions, and allocation of adequate resources. Regarding beneficence/nonmaleficence, resuscitation should benefit patients, while avoiding harm from futile interventions; pertinent practice should be based on neurological prognostication and patient/family-reported outcomes. Regarding dignity, aggressive life-sustaining treatments against patients preferences should be avoided. Contrary to the principle of justice, resuscitation quality may be affected by race/income status, age, ethnicity, comorbidity, and location (urban versus rural or country-specific/region-specific). Current evidence supports family presence during resuscitation. Regarding emergency research, autonomy should be respected without hindering scientific progress; furthermore, transparency of research conduct should be promoted and funding increased.

CONCLUSIONS

Major ethical challenges in resuscitation science need to be addressed through complex/resource-demanding interventions. Such actions require support by ongoing/future research.