The Utstein template and the effect of in-hospital decisions: the impact of do-not-attempt resuscitation status on survival to discharge statistics

Influences of "do-not-resuscitate order" prohibition on CPR outcomes

OBJECTIVES

The aim of the study is to determine factors affecting the return of spontaneous circulation (ROSC) ratios, neurological outcomes at discharge, the ratio of living patients discharged from the hospital and due to Do not attempt resuscitation (DNAR) prohibition.

MATERIAL AND METHODS

This is a retrospective observational study conducted on patients of cardiopulmonary resuscitation (CPR) performed in emergency department (ED) and intensive care units between February 2010 and February 2012.

RESULTS

A total of 469 patients were evaluated, and 266 eligible patients who did not have DNAR orders were included in the study. Overall, 45.1% of the adult in-hospital cardiac arrest victims returned to spontaneous circulation, and 5.3% survived to hospital discharge. Of the patients who were discharged alive from the hospital, 33.3% were discharged in poor neurologic conditions of Cerebral Performance Category (CPC) score 3 or 4. The ROSC ratio was reduced for the patients with malignancies compared to the patients with other preexisting conditions (OR: 12.783; 95% CI 2.967-55.072; p = 0.000). None of the patients with malignancies were discharged alive from the hospital. Only one patient with end-stage disease was discharged alive from hospital, and this patient's CPC score was 4.

DISCUSSION AND CONCLUSION

CPR has not increased the ROSC and alive discharge rates in patients with malignancy and end-state disease. DNAR order prohibition have been increased the futile CPR attempts. DNAR should be accepted as a human right that represents an honorable death option and whether a DNAR is order demanded should be specifically discussed with patients with malignancies and end-stage disease presenting to ED.

Alignment of Do-Not-Resuscitate Status With Patients' Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest

IMPORTANCE

After patients survive an in-hospital cardiac arrest, discussions should occur about prognosis and preferences for future resuscitative efforts.

OBJECTIVE

To assess whether patients' decisions for do-not-resuscitate (DNR) orders after a successful resuscitation from in-hospital cardiac arrest are aligned with their expected prognosis.

DESIGN, SETTING, AND PARTICIPANTS

Within Get With The Guidelines-Resuscitation, we identified 26,327 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest between April 2006 and September 2012 at 406 US hospitals. Using a previously validated prognostic tool, each patient's likelihood of favorable neurological survival (ie, without severe neurological disability) was calculated. The proportion of patients with DNR orders within each prognosis score decile and the association between DNR status and actual favorable neurological survival were examined.

EXPOSURES

Do-not-resuscitate orders within 12 hours of ROSC.

MAIN OUTCOMES AND MEASURES

Likelihood of favorable neurological survival.

RESULTS

Overall, 5944 (22.6% [95% CI, 22.1%-23.1%]) patients had DNR orders within 12 hours of ROSC. This group was older and had higher rates of comorbidities (all P < .05) than patients without DNR orders. Among patients with the best prognosis (decile 1), 7.1% (95% CI, 6.1%-8.1%) had DNR orders even though their predicted rate of favorable neurological survival was 64.7% (95% CI, 62.8%-66.6%). Among patients with the worst expected prognosis (decile 10), 36.0% (95% CI, 34.2%-37.8%) had DNR orders even though their predicted rate for favorable neurological survival was 4.0% (95% CI, 3.3%-4.7%) (P for both trends <.001). This pattern was similar when DNR orders were redefined as within 24 hours, 72 hours, and 5 days of ROSC. The actual rate of favorable neurological survival was higher for patients without DNR orders (30.5% [95% CI, 29.9%-31.1%]) than it was for those with DNR orders (1.8% [95% CI, 1.6%-2.0%]). This pattern of lower survival among patients with DNR orders was seen in every decile of expected prognosis.

CONCLUSIONS AND RELEVANCE

Although DNR orders after in-hospital cardiac arrest were generally aligned with patients' likelihood of favorable neurological survival, only one-third of patients with the worst prognosis had DNR orders. Patients with DNR orders had lower survival than those without DNR orders, including those with the best prognosis.

A prospective study to determine the circumstances, incidence and outcome of cardiopulmonary resuscitation in a referral hospital in India, in relation to various factors

Background and Aims:

Cardiac arrest has multifactorial aetiology and the outcome depends on timely and correct interventions. We decided to investigate the circumstances, incidence and outcome of cardiopulmonary resuscitation (CPR) at a tertiary hospital in India, in relation to various factors, including extensive basic life support and advanced cardiac life support training programme for all nurses and doctors.

Methods:

It has been over a decade and a half with periodical updates and implementation of newer guidelines prepared by various societies across the world about CPR for both in-hospital and out-of hospital cardiac arrests (IHCA and OHCA). We conducted a prospective study wherein all cardiac arrests reported in the hospital consecutively for 12 months were registered for the study and followed their survival up to 1-year. Statistical analysis was performed by using Chi-square test for significant differences in proportions applied to various parameters of the study.

Results:

The main outcome measures were; (following CPR) return of spontaneous circulation, survival for 24 h, survival from 24 h to 6 weeks or discharge, alive at 1-year. For survivors, an assessment was made about their cerebral performance and overall performance and accordingly graded. All these data were tabulated. Totally 419 arrests were reported in the hospital, out of which 413 were in-hospital arrests. Out of this 260 patients were considered for resuscitation, we had about 27 survivors at the end of 1-year follow-up (10.38%).

Conclusion:

We conclude by saying there are many factors involved in good clinical outcomes following IHCAs and these variable factors need to be researched further.

Finding the key to a better code: code team restructure to improve performance and outcomes

Code teams respond to acute life threatening changes in a patient's status 24 hours a day, 7 days a week. If any variable, whether a medical skill or non-medical quality, is lacking, the effectiveness of a code team's resuscitation could be hindered. To improve the overall performance of our hospital's code team, we implemented an evidence-based quality improvement restructuring plan. The code team restructure, which occurred over a 3-month period, included a defined number of code team participants, clear identification of team members and their primary responsibilities and position relative to the patient, and initiation of team training events and surprise mock codes (simulations). Team member assessments of the restructured code team and its performance were collected through self-administered electronic questionnaires. Time-to-defibrillation, defined as the time the code was called until the start of defibrillation, was measured for each code using actual time recordings from code summary sheets. Significant improvements in team member confidence in the skills specific to their role and clarity in their role's position were identified. Smaller improvements were seen in team leadership and reduction in the amount of extra talking and noise during a code. The average time-to-defibrillation during real codes decreased each year since the code team restructure. This type of code team restructure resulted in improvements in several areas that impact the functioning of the team, as well as decreased the average time-to-defibrillation, making it beneficial to many, including the team members, medical institution, and patients.

Resuscitation Outcomes Consortium (ROC) PRIMED cardiac arrest trial methods part 2: rationale and methodology for "Analyze Later vs. Analyze Early" protocol

OBJECTIVE

The primary objective of the trial is to compare survival to hospital discharge with modified Rankin score (MRS) < or =3 between a strategy that prioritizes a specified period of CPR before rhythm analysis (Analyze Later) versus a strategy of minimal CPR followed by early rhythm analysis (Analyze Early) in patients with out-of-hospital cardiac arrest.

METHODS

Design-Cluster randomized trial with cluster units defined by geographic region, or monitor/defibrillator machine. Population-Adults treated by emergency medical service (EMS) providers for non-traumatic out-of-hospital cardiac arrest not witnessed by EMS. Setting-EMS systems participating in the Resuscitation Outcomes Consortium and agreeing to cluster randomization to the Analyze Later versus Analyze Early intervention in a crossover fashion. Sample size-Based on a two-sided significance level of 0.05, a maximum of 13,239 evaluable patients will allow statistical power of 0.996 to detect a hypothesized improvement in the probability of survival to discharge with MRS < or =3 rate from 5.41% after Analyze Early to 7.45% after Analyze Later (2.04% absolute increase in primary outcome).

CONCLUSION

If this trial demonstrates a significant improvement in survival with a strategy of Analyze Later, it is estimated that 4000 premature deaths from cardiac arrest would be averted annually in North America alone.

Variation in the rates of do not resuscitate orders after major trauma and the impact of intensive care unit environment

BACKGROUND

There is an increased emphasis on benchmarking of trauma mortality outcomes as a measure of quality. Differences in approaches to end-of-life care or perceptions of salvageability might account for some of the variability in outcomes across centers. We postulated that these differences in perceptions or practice might lead to significant variation in the use of do not resuscitate (DNR) orders and sought to identify institutional characteristics associated with their use.

METHODS

Patients surviving >24 hours and admitted to an intensive care unit (ICU) in one of 68 centers across the United States were identified from a large prospective cohort study of severely injured patients. Independent predictors of a DNR order at both the patient and institutional level were identified using multivariate hierarchical modeling stratified by age <55 or >/=55.

RESULTS

Of 6,765 patients, 7% had a DNR order, of whom 88% died. The proportion of patients in each center with a DNR order ranged from 0% to 57%. Independent patient-level predictors associated with a DNR order were increasing age, preinjury comorbidity burden, severe injury, and organ failure. Institutional predictors of DNR orders differed by age. Care in an open ICU was associated with a DNR order (odds ratio, 1.7; 95% confidence interval, 1.0-3.0) in the elderly, whereas care in a combined medical-surgical ICU (vs. surgical or trauma ICU) was associated with greater likelihood (odds ratio, 2.0; 95% confidence interval, 1.1-4.1) of a DNR order in the young.

CONCLUSIONS

DNR orders are relatively common in seriously injured trauma patients, and there is significant variability in their use across centers. Given the institutional characteristics independently associated with DNR status, it is likely that both differences in the ethos of end-of-life care and perceptions of salvageability affect decision making.

Comparison of the effects of hypothermia at 33 degrees C or 35 degrees C after cardiac arrest in rats

OBJECTIVES

Hypothermia of 32 degrees C-34 degrees C induced after resuscitation from cardiac arrest improves neurologic recovery, but the optimal depth of cooling is unknown. Using a rat model, the authors tested the hypothesis that cooling to 35 degrees C between hours 1 and 24 after resuscitation would improve neurologic outcome as much as cooling to 33 degrees C.

METHODS

Halothane-anesthetized rats (n = 38) underwent 8 minutes of asphyxial cardiac arrest and resuscitation. Cranial temperature was maintained at 37 degrees C before, during, and after arrest. Between one and 24 hours after resuscitation, cranial temperature was maintained at 33 degrees C, 35 degrees C, or 37 degrees C using computer-controlled cooling fans and heating lamps. Neurologic scores were measured daily, and rats were killed at 14 days for histologic analysis. Neurons per high-powered field were counted in the CA1 region of the anterior hippocampus using neuronal nuclear antigen staining.

RESULTS

After 14 days, 12 of 12 rats (100%) cooled to 33 degrees C, 11 of 12 rats (92%) cooled to 35 degrees C, and ten of 14 rats (71%) cooled to 37 degrees C survived, with hazard of death greater in the rats cooled to 37 degrees C than in the combined hypothermia groups. Neurologic scores were worse in the rats cooled to 37 degrees C than in the hypothermia groups on days 1, 2, and 3. Numbers of surviving neurons were similar between the groups cooled to 33 degrees C and 35 degrees C and were higher than in the group cooled to 37 degrees C.

CONCLUSIONS

These data illustrate that hypothermia of 35 degrees C or 33 degrees C over the first day of recovery improves neurologic scores and neuronal survival after cardiac arrest in rats. The benefit of induced hypothermia of 35 degrees C appears to be similar to the benefit of 33 degrees C.

Usefulness of vasopressin administered with epinephrine during out-of-hospital cardiac arrest

Vasopressin administration has been suggested during cardiopulmonary resuscitation, and a previous clinical trial has suggested that vasopressin is most effective when administered with epinephrine. Adult subjects (n = 325) who received > or =1 dose of intravenous epinephrine during cardiopulmonary resuscitation for nontraumatic, out-of-hospital cardiac arrest were randomly assigned to receive 40 IU of vasopressin (n = 167) or placebo (n = 158) as soon as possible after the first dose of epinephrine. The rate of return of pulses was similar between the vasopressin and placebo groups (31% vs 30%), as was the presence of pulses at the emergency department (19% vs 23%). No subgroup appeared to be differentially affected, and no effect of vasopressin was evident after adjustment for other clinical variables. Additional open-label vasopressin was administered by a physician after the study drug for 19 subjects in the placebo group and 27 subjects in the vasopressin group. Results were similar if these subjects were excluded or were assigned to an actual drug received. Survival duration for subjects admitted to the hospital did not differ between groups. In conclusion, vasopressin administered with epinephrine does not increase the rate of return of spontaneous circulation.

In-hospital cardiac arrest: Is outcome related to the time of arrest?

BACKGROUND

Whether outcome from in-hospital cardiopulmonary resuscitation (CPR) is poorer when it occurs during the night remains controversial. This study examined the relationship between CPR during the various hospital shifts and survival to discharge.

METHODS

CPR attempts occurring in a tertiary hospital with a dedicated, certified resuscitation team were recorded prospectively (Utstein template guidelines) over 24 months. Medical records and patient characteristics were retrieved from patient admission files.

RESULTS

Included were 174 in-hospital cardiac arrests; 43%, 32% and 25% in morning evening and night shifts, respectively. Shift populations were comparable in demographic and treatment related variables. Asystole (p < 0.01) and unwitnessed arrests (p = 0.05) were more common during the night. Survival to discharge was poorer following night shift CPR than following morning and evening shift CPR (p = 0.04). When asystole (being synonymous with death) was excluded from the analysis, the odds of survival to discharge was not higher for witnessed compared to unwitnessed arrest but was 4.9 times higher if the cardiac arrest did not occur during the night shift (p = 0.05, logistic regression). The relative risk of eventual in-hospital death for patients with return of spontaneous circulation (ROSC) following night shift resuscitation was 1.9 that of those with ROSC following morning or evening resuscitation (Cox regression).

CONCLUSIONS

Although unwitnessed arrest is more prevalent during night shift, resuscitation during this shift is associated with poorer outcomes independently of witnessed status. Further research is required into the causes for the increased mortality observed after night shift resuscitation.

In-hospital cardiac resuscitation outside the ICU by nursing staff equipped with automated external defibrillators—The first 500 cases

BACKGROUND

Since nursing staff in the hospital are frequently the first to witness a cardiac arrest, they may play a central role in the effective management of in-hospital cardiac arrest. In this retrospective study the first 500 in-hospital cardiac arrests in non-monitored areas, which were treated initially by nursing staff equipped with automated external defibrillators (AEDs) are reported.

METHODS AND RESULTS

Between April 2001 and December 2004, 500 in-hospital cardiac arrest calls were made: there were false arrests in 61 patients, so a total of 439 patients (88%) were evaluated using the Utstein style of data collection. ROSC occurred in 256 patients (58%), 125 (28%) were discharged from hospital and 95 (22%) were still alive 6 months after discharge. Among the 73 patients with VF/VT 63 (86%) had ROSC, 34 (47%) were discharged from hospital and 28 (38%) were alive after 6 months. The chance of survival was not influenced by the time between the call of the arrest team and the 1st defibrillation but was slightly higher with physicians as in-hospital first responders (p=0.078). In contrast, 366 patients with non-VF/VT, 193 (53%) had ROSC, but only 91 (25%) were discharged from hospital and 67 (18%) were alive after 6 months. The risk of dying was significantly higher in patients with non-VF/VT (p<0.001), and there was a trend to a higher risk ratio in patients older than 65 years and in patients with non-witnessed cardiac arrest (p=0.056 and 0.079, respectively).

CONCLUSION

This observational study supports the concept of hospital-wide first responder resuscitation performed by nursing staff before the arrival of the CPR-team. Among these patients survival rate was higher in those with VF/VT defibrillated at an early stage. Consequently, it may be assumed that patients may die unnecessarily due to sudden cardiac arrest if proper in-hospital resuscitation programmes are not available.

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.

Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation

The National Registry of Cardiopulmonary Resuscitation (NRCPR) is an American Heart Association (AHA)-sponsored, prospective, multisite, observational study of in-hospital resuscitation. The NRCPR is currently the largest registry of its kind. The purpose of this article is to describe the NRCPR and to provide the first comprehensive, Utstein-based, standardized characterization of in-hospital resuscitation in the United States. All adult (>/=18 years of age) and pediatric (<18 years of age) patients, visitors, employees, and staff within a facility (including ambulatory care areas) who experience a resuscitation event are eligible for inclusion in the NRCPR database. Between January 1, 2000, and June 30, 2002, 14720 cardiac arrests that met inclusion criteria occurred in adults at the 207 participating hospitals. An organized emergency team is available 24 h a day, 7 days a week in 86% of participating institutions. The three most common reasons for cardiac arrest in adults were (1) cardiac arrhythmia, (2) acute respiratory insufficiency, and (3) hypotension. Overall, 44% of adult in-hospital cardiac arrest victims had a return of spontaneous circulation (ROSC); 17% survived to hospital discharge. Despite the fact that a primary arrhythmia was one of the precipitating events in nearly one half of adult cardiac arrests, ventricular fibrillation (VF) was the initial pulseless rhythm in only 16% of in-hospital cardiac arrest victims. ROSC occurred in 58% of VF cases, yielding a survival-to-hospital discharge rate of 34% in this subset of patients. An automated external defibrillator was used to provide initial defibrillation in only 1.4% of patients whose initial cardiac arrest rhythm was VF. Neurological outcome in discharged survivors was generally good. Eighty-six percent of patients with Cerebral Performance Category-1 (CPC-1) at the time of hospital admission had a postarrest CPC-1 at the time of hospital discharge.

Prehospital ACLS--does it work?

Cardiac disease is the most common cause of death in the United States, and sudden cardiac arrest frequently claims the lives of men and women during their most productive years. It is believed that much better survival rates can be achieved for victims of cardiac arrest through optimizing the "chain of survival" as described by the American Heart Association. The relative and incremental benefit of full prehospital ACLS over basic life support and defibrillation is unproven, however. This is an important issue in this era of cost containment. Some of the ongoing studies including the OPALS study may clarify the cost effectiveness and relative efficacy of rapid defibrillation and full ACLS programs for victims of prehospital cardiac arrest [6].

Reconsideration of proximate Utstein-style end points

The Utstein-style template defines core and supplementary data for reporting out-of-hospital cardiac arrest information. The primary outcome statistic of the Utstein template is survival to hospital discharge (SHD). The SHD statistic is dependent on Utstein-defined out-of-hospital variables and multiple in-hospital variables that are undefined and uncontrolled. An example of one of these undefined in-hospital variables is the decision to place a patient on do-not-resuscitate status. At our municipal teaching hospital, 418 patients who had out-of-hospital cardiac arrest presented over a 4-yr period; 79 (19%; 95% confidence interval [CI], 15% to 23%) survived to hospital admission, with 54 (68%; 95% CI, 57% to 78%) subsequently being placed on do-not-resuscitate status. When patients on do-not-resuscitate status were included in the SHD calculation, the SHD rate was 5.3% (95% CI, 3.3% to 7.8%), and when patients on do-not-resuscitate status were excluded from the SHD calculation, the SHD rate was 6.1% (95% CI, 3.8% to 9.0%). These data show a relative 15% change in SHD resulting from a single in-hospital variable. Cardiac arrest survivors represent a small proportion of a total population; therefore, large numbers of study subjects are required for a statistically significant interpretation of the SHD statistic. This requirement for large study populations has resulted in recent studies that report results by using end points proximate to SHD when assessing the effect of individual interventions. It is logical that success of a specific intervention should be determined by the ability of the intervention to accomplish its purpose rather than the ability to improve SHD that is dependent on multiple variables. Furthermore, because in-hospital care is not standardized and uncontrolled variables exist, the primary Utstein end point of SHD should be reconsidered when evaluating cardiac arrest interventions.