Cardiopulmonary resuscitation: what cost to cheat death?

Chronic Critical Illness: Are We Just Adding Years to Life?

How to cite this article: Ramakrishnan N. Chronic Critical Illness: Are We Just Adding Years to Life? Indian J Crit Care Med 2020;25(5):482-483.

Cardiopulmonary Resuscitation in Patients With Cancer

Cancer is the second leading cause of death in the United States, with most of these deaths taking place in the hospital setting. Discussions on end-of-life care and on cardiopulmonary resuscitation in particular are an important component in the management of patients with cancer. Clinical decision making and respect for patient autonomy dictate that health care providers provide their patients with accurate information on the expected outcomes of cardiopulmonary resuscitation. This article reviews those factors that affect the outcome of cardiopulmonary resuscitation in patients with cancer and provides recommendations on obtaining do-not-resuscitate orders in these patients.

Hospital charges for a community inpatient palliative care program

Defining financial parameters of palliative care (PC) is important for providing sustainable programming. In our study, we evaluated hospital length of stay (LOS) and charges for the first 164 inpatient PC consultations performed by the Advanced Illness Assistance (AIA) team at Blount Memorial Hospital (BMH). These AIA patients had a median LOS of 11 days (range, 3-114 days), mean total charges per patient of $65,795, and mean daily charges of $3,809. Higher mean daily charges (p = 2.74 E-08, chi-square) were associated with patients who received consultation because of nonphysical symptom reasons. Patients were followed in PC consultation (AIA follow-up days) for a median of five days (range, 1-48), and had mean daily charges of $3,117. These mean daily charges were $414 less than the charges for the five days prior to PC consultation (pre-AIA days) (p = 0.04, t-test). There was a significant decrease in laboratory and imaging charges during AIA follow-up (p = 0.04, t-test).

The study included a reference group of patients whose information was obtained retrospectively from the BMH Atlas ® (MediQual, Marlborough, MA) database. These reference group patients were hospitalized at BMH during the same time, but they were not seen by the AIA team. The reference group was matched by Diagnosis Related Group (DRG), Admission Severity Grade (ASG), and disposition to the AIA patients. The Atlas patients had a shorter median LOS of six days (range, 1-105 days), and significantly greater mean daily charges of $4,105 (p = 0.006, t-test) compared with AIA patients. Mean daily charges decreased for Atlas patients, as their day of discharge approached (p < 0.001).

Estimates of potential charge savings were calculated in two ways: 1) by evaluating the effect of decreasing the LOS of Atlas patients with long LOS (more than seven days) to the level of AIA patients with long LOS, and 2) by comparing the actual mean patient charges during AIA follow-up with using the pre-AIA mean daily charges during the AIA follow-up period and correcting for the effect of decreasing charges that occurred as discharge approached. The estimated savings achieved by decreasing long LOS were more than $100,000 per year, and estimated savings achieved using AIA follow-up charges were more than $1,801,930 per year.

Education for cardiac arrest--Treatment or prevention?

In-hospital cardiac arrests (IHCA) occur infrequently and individual staff members working on general wards may only rarely encounter one. Mortality following IHCA is high and the evidence for the benefits of many advanced life support (ALS) interventions is scarce. Nevertheless, regular, often frequent, ALS training is mandatory for many hospital medical staff and nurses. The incidence of pre-cardiac arrest deterioration is much higher than that of cardiac arrests, and there is evidence that intervention prior to cardiac arrest can reduce the incidence of IHCA. This article discusses a proposal to reduce the emphasis on widespread ALS training and to increase education in the recognition and response to pre-arrest clinical deterioration.

DVT surveillance program in the ICU: analysis of cost-effectiveness

BACKGROUND

Venous Thrombo-embolism (VTE--Deep venous thrombosis (DVT) and/or pulmonary embolism (PE)--in traumatized patients causes significant morbidity and mortality. The current study evaluates the effectiveness of DVT surveillance in reducing PE, and performs a cost-effectiveness analysis.

METHODS

All traumatized patients admitted to the adult ICU underwent twice weekly DVT surveillance by bilateral lower extremity venous Duplex examination (48-month surveillance period--SP). The rates of DVT and PE were recorded and compared to the rates observed in the 36-month pre-surveillance period (PSP). All patients in both periods received mechanical and pharmacologic prophylaxis unless contraindicated. Total costs--diagnostic, therapeutic and surveillance--for both periods were recorded and the incremental cost for each Quality Adjusted Life Year (QALY) gained was calculated.

RESULTS

4234 patients were eligible (PSP--1422 and SP--2812). Rate of DVT in SP (2.8%) was significantly higher than in PSP (1.3%) - p<0.05, and rate of PE in SP (0.7%) was significantly lower than that in PSP (1.5%) - p<0.05. Logistic regression demonstrated that surveillance was an independent predictor of increased DVT detection (OR: 2.53 - CI: 1.462-4.378) and decreased PE incidence (OR: 0.487 - CI: 0.262-0.904). The incremental cost was $509,091/life saved in the base case, translating to $29,102/QALY gained. A sensitivity analysis over four of the parameters used in the model indicated that the incremental cost ranged from $18,661 to $48,821/QALY gained.

CONCLUSIONS

Surveillance of traumatized ICU patients increases DVT detection and reduces PE incidence. Costs in terms of QALY gained compares favorably with other interventions accepted by society.

Cost and health care utilization in ARDS--different from other critical illness?

Costs of care in the intensive care unit are a frequent target for concern in the current health care system. Utilization of critical care services in the United States is increasing and will continue to do so. Acute respiratory distress syndrome (ARDS) is a common and important complication of critical illness. Patients with ARDS frequently have long hospitalizations and consume a significant amount of health care resources. Many patients are discharged with functional limitations and high susceptibility to new complications that require significant additional health care resources. There is increasing literature on the cost-effectiveness of the treatment of ARDS, and despite its high costs, treatment remains a cost-effective intervention by current societal standards. However, when ARDS leads to prolonged mechanical ventilation, treatment becomes less cost-effective. Current research seeks to find interventions that lead to reductions in duration of mechanical ventilation and intensive care unit (ICU) length of stay. Limited reductions in ICU length of stay have benefits for the patient, but they do not lead to significant reductions in overall hospital costs. Early discharge to post-acute care facilities can reduce hospital costs but are unlikely to decrease costs for an entire episode of illness. Improved effectiveness of communication between clinicians and patients or their surrogates could help avoid costly interventions with poor expected outcomes.

In-hospital cardiac arrest: can we change something?

Cardiac arrest is classified as 'in-hospital' if it occurs in a hospitalised patient who had a pulse at the time of admission. A probability of patient's survival until hospital discharge is very low. The reasons for this are old age, multiple co-morbidity of patients, late recognition of cardiac arrest, poor knowledge about basic life support algorithm, insufficient equipment, absence of qualified resuscitation teams (RTs) and poor organization.The aim of this study was to demonstrate characteristics of in-hospital cardiac arrests and resuscitation measures in University Hospital Osijek. We analysed retrospectively all resuscitation procedures data where anaesthesiology RTs provided cardiopulmonary resuscitation (CPR) during 5-year period.We analysed 309 in-hospital resuscitation attempts with complete documentation. Victims of cardiac arrest were principally elderly patients, neurological (30.4 %), surgical (25.24 %) and neurosurgical patients (15.2 %) with many associated severe diseases. In 85.6 % of the cases, resuscitation was initiated by ward personnel and RTs arrived within 5 min in 67 % of the cases. However, in 14.6 % of the cases resuscitation measures had not been started before RT arrival. We found statistical correlation between lower initial survival rates and length of hospital stay (p = 0.001), presence of cerebral ischemia (p = 0.026) or cardiomyopathy (p = 0.004) and duration of CPR (p = 0.041). Initial survival was very low (14.6 %), and full recovery was accomplished in only eight patients out of 309 (2.59 %).Identification of terminal chronic patients in which the CPR is not reasonable, a better organisation and ward personnel education can contribute to better overall success.

Health care costs related to out-of-hospital cardiopulmonary arrest in Japan

OBJECTIVES

Although cost analyses for emergency care are essential, data on costs of care for out-of-hospital cardiopulmonary arrest (OHCA) are scarce. The present study aimed to analyze health care costs related to OHCA using a nationwide administrative database in Japan.

METHODS

Using the Diagnosis Procedure Combination database in Japan, we identified OHCA patients who were transported to 779 emergency medical centres between July and December in 2008 and 2009. We assessed patient survival and discharge status, receipt of specific treatments, and costs of in-hospital care.

RESULTS

A total of 21,750 OHCA patients were identified. Overall, 59.6% were males, and the average age was 70.3 years. Of them, 1394 (6.4%) resulted in death without attempted resuscitation after hospital arrival (Group A), 14,973 (69.0%) died on admission day despite resuscitation attempts (Group B), 3680 (17.0%) died at ≥2 days after admission despite resuscitation attempts (Group C), 785 (3.6%) survived and were discharged to home (Group D) and 873 (4.0%) survived and discharged to other than home (Group E). The median total costs were $434, $1735, $4869, $28,097 and $31,161 in Groups A to E, respectively. Positive survival status, longer hospital stay and receipt of specific treatments were significant predictors of higher total costs. After adjustment for these factors, higher age was associated with lower costs.

CONCLUSIONS

The findings in the present study add further evidence to existing knowledge about healthcare costs related to OHCA.

Pneumothorax During CPR Training: Case Report and Review of the CPR Literature

Cardiopulmonary resuscitation is taught widely to both lay persons and health care oworkers. It is a challenging psychomotor skill. Concerns about its safety to the rescuer have centered around the risk of infectious disease exposure. A young nursing assistant developed a minimally symptomatic pneumothorax during CPR training. This case is the first reported example of this complication for a CPR trainee or provider. The literature is reviewed for complications for CPR provider and recipient and the relevant issues regarding the current status and future direction of this intervention.

Termination of resuscitation of nontraumatic cardiopulmonary arrest: resource document for the National Association of EMS Physicians position statement

In the development of an emergency medical services (EMS) system, medical directors should consider the implementation of protocols for the termination of resuscitation (TOR) of nontraumatic cardiopulmonary arrest. Such protocols have the potential to decrease unnecessary use of warning lights and sirens and save valuable public health resources. Termination-of-resuscitation protocols for nontraumatic cardiopulmonary arrest should be based on the determination that an EMS provider did not witness the arrest, there is no shockable rhythm identified, and there is no return of spontaneous circulation (ROSC) prior to EMS transport. Further research is needed to determine the need for direct medical oversight in TOR protocols and the duration of resuscitation prior to EMS providers' determining that ROSC will not be achieved. This paper is the resource document to the National Association of EMS Physicians position statement on the termination of resuscitation for nontraumatic cardiopulmonary arrest.

Focused nurse-defibrillation training: a simple and cost-effective strategy to improve survival from in-hospital cardiac arrest

Time to first defibrillation is widely accepted to correlate closely with survival and recovery of neurological function after cardiac arrest due to ventricular fibrillation or ventricular tachycardia. Focused training of a cadre of nurses to defibrillate on their own initiative may significantly decrease time to first defibrillation in cases of in-hospital cardiac arrest outside of critical care units. Such a program may be the best single strategy to improve in-hospital survival, simply and at reasonable cost.

Cost-effectiveness of implementing low-tidal volume ventilation in patients with acute lung injury

BACKGROUND

Despite widespread guidelines recommending the use of lung-protective ventilation (LPV) in patients with acute lung injury (ALI), many patients do not receive this lifesaving therapy. We sought to estimate the incremental clinical and economic outcomes associated with LPV and determined the maximum cost of a hypothetical intervention to improve adherence with LPV that remained cost-effective.

METHODS

Adopting a societal perspective, we developed a theoretical decision model to determine the cost-effectiveness of LPV compared to non-LPV care. Model inputs were derived from the literature and a large population-based cohort of patients with ALI. Cost-effectiveness was determined as the cost per life saved and the cost per quality-adjusted life-years (QALYs) gained.

RESULTS

Application of LPV resulted in an increase in QALYs gained by 15% (4.21 years for non-LPV vs 4.83 years for LPV), and an increase in lifetime costs of $7,233 per patient with ALI ($99,588 for non-LPV vs $106,821 for LPV). The incremental cost-effectiveness ratios for LPV were $22,566 per life saved at hospital discharge and $11,690 per QALY gained. The maximum, cost-effective, per patient investment in a hypothetical program to improve LPV adherence from 50 to 90% was $9,482. Results were robust to a wide range of economic and patient parameter assumptions.

CONCLUSIONS

Even a costly intervention to improve adherence with low-tidal volume ventilation in patients with ALI reduces death and is cost-effective by current societal standards.

Serum S100B levels after meningioma surgery: A comparison of two laboratory assays

Background

S100B protein is a potential biomarker of central nervous system insult. This study quantitatively compared two methods for assessing serum concentration of S100B.

Methods

A prospective, observational study performed in a single tertiary medical center. Included were fifty two consecutive adult patients undergoing surgery for meningioma that provided blood samples for determination of S100B concentrations. Eighty samples (40 pre-operative and 40 postoperative) were randomly selected for batch testing. Each sample was divided into two aliquots. These were analyzed by ELISA (Sangtec) and a commercial kit (Roche Elecsys^®) for S100B concentrations. Statistical analysis included regression modelling and Bland-Altman analysis.

Results

A parsimonious linear model best described the prediction of commercial kit values by those determined by ELISA (y = 0.045 + 0.277*x, x = ELISA value, R² = 0.732). ELISA measurements tended to be higher than commercial kit measurements. This discrepancy increased linearly with increasing S100B concentrations. At concentrations above 0.7 μg/L the paired measurements were consistently outside the limits of agreement in the Bland-Altman display. Similar to other studies that used alternative measurement methods, sex and age related differences in serum S100B levels were not detected using the Elecsys^® (p = 0.643 and 0.728 respectively).

Conclusion

Although a generally linear relationship exists between serum S100B concentrations measured by ELISA and a commercially available kit, ELISA values tended to be higher than commercial kit measurements particularly at concentrations over 0.7 μg/L, which are suggestive of brain injury. International standardization of commercial kits is required before the predictive validity of S100B for brain damage can be effectively assessed in clinical practice.

Anesthesiologists on ambulances: where do we stand?

PURPOSE OF REVIEW

This manuscript provides a critical review of the literature regarding the staffing of emergency medical services, with particular emphasis on anesthesiologists.

RECENT FINDINGS

Significant anesthesiology contributions to prehospital care include introduction of new airway management tools and improved physiological monitoring. Contributions to quality of care include patient benefit in terms of life years gained and a specific reduction in mortality from acute myocardial infarction. Intuitive concepts regarding the advantage of anesthesiologists in intubation mishaps and management of the failed airway have yet to be proven. Personnel limitations may be regional, necessitating local evaluation of anesthesiologist availability to staff ambulances. Since a major part of cost-effectiveness research is performed in the US where only paramedics staff ambulances, insufficient data exist regarding the financial implications of such practice. Burnout may be an important factor for deciding whether anesthesiologists should work in the operating room or ambulances or on an alternate basis.

SUMMARY

Further research should be performed to evaluate the clinical and financial implications of staffing ambulances with anesthesiologists or other physicians. Randomized controlled studies using standardized intubation techniques are necessary to examine whether prehospital airway management is improved when delivered by anesthesiologists.

Cost-effectiveness of automated external defibrillators in public places: con

PURPOSE OF REVIEW

To discuss the clinical effectiveness, public health impact and cost-effectiveness of public access defibrillation.

RECENT FINDINGS

High rates of survival from prehospital ventricular fibrillation have been documented in patients treated by first responders using automated external defibrillators. The recent Public Access Defibrillation trial demonstrated a doubling of cardiac arrest survival in community units where volunteers trained in cardiopulmonary resuscitation were additionally equipped with automated external defibrillators. The cost-effectiveness analysis of the Public Access Defibrillation trial has not yet been published, and previous analyses have lacked full data on cost, outcome, or both. Data from many sources indicate that automated external defibrillator placement at sites with an expected rate of one cardiac arrest per defibrillator per 5 years, as recommended by the American Heart Association, addresses only around 1-2% of prehospital arrests, and will have a minimal impact on population survival.

SUMMARY

While highly targeted provision of automated external defibrillators in areas of greatest risk, such as casinos and airports, may be cost-effective, it will have little impact at a population level. Provision of more widespread public access defibrillation to sites with lower incidence of cardiac arrest is unlikely to be cost-effective, and may represent poorer value for money than alternative healthcare interventions in coronary artery disease.

In-hospital cardiac arrest

To review the current management of in-hospital cardiac arrest and to identify variables that influence outcomes, OLDMEDLINE from 1950 to 1966 and MEDLINE from 1966 to March 2005 were searched using the keywords cardiopulmonary resuscitation, cardiac arrest, in hospital, and adult. Secondary sources were derived from review publications and personal communications by one of the authors. There is no secure evidence that the ultimate outcomes after cardiopulmonary resuscitation in settings of in-hospital cardiac arrest have improved in the >40 yrs that followed the landmark report by Kouwenhoven, Jude, and Knickerbocker, which launched the modern era of cardiopulmonary resuscitation. A paucity of objective measurements preclude secure protocols for sequencing of interventions and, even more, when to initiate and discontinue cardiopulmonary resuscitation. The preparedness of both physicians and nursing professionals to implement the published guidelines has itself been questioned. Whereas early access defibrillation with automated external defibrillators may be of benefit in out-of-hospital settings, there has as yet been no secure evidence that automated external defibrillators have had a favorable impact on in-hospital cardiopulmonary resuscitation when used on infrequent occasions by first responders. This contrasts with the much greater success of advanced life support providers and especially when electrical defibrillation is promptly performed by expertly trained personnel after onset of cardiac arrest. Outcomes are therefore improved in critical care settings and especially in coronary care units in which patients are continuously monitored.

Cost effectiveness and cost utility model of public place defibrillators in improving survival after prehospital cardiopulmonary arrest

OBJECTIVE

To determine the cost effectiveness and cost utility of locating defibrillators in all major airports, railway stations, and bus stations throughout Scotland.

DESIGN

Economic modelling exercise with data from Heartstart (Scotland). Parameters used in economic model included direct costs derived for increased accident and emergency attendances, increased hospital bed days, purchase and maintenance of defibrillators, and training in their use; life years gained calculated from increased discharges from hospital and mean survival after discharge; utility (quality of life) obtained from published data. Sensitivity analyses tested the robustness of model. Future gains discounted at 1.5% a year and future costs at 6%.

SETTING

Whole of Scotland.

SUBJECTS

Records of all prehospital cardiac arrests due to presumed heart disease that occurred in a major airport, railway, or bus station between May 1991 and March 1998 and were not witnessed by ambulance or medical staff.

MAIN OUTCOME MEASURES

Observed survival to hospital admission and observed survival to discharge. Predicted survival calculated by applying observed survival in patients attended by ambulance staff within three minutes to those who waited longer.

RESULTS

The total discounted direct costs were 18 325 pounds sterling a year. The cost per life year gained was 29 625 pounds sterling (49 625 dollars, 43 151 Euros) and the cost per quality adjusted life year (QALY) gained was pound 41 146 (68 924 dollars, 59 932 Euros). More widespread provision of public place defibrillators would increase these figures.

CONCLUSIONS

The cost per QALY calculated for public place defibrillators represents poorer value for money than some alternative strategies for improving survival after prehospital cardiopulmonary arrest, such as the use of other trained first responders. The figure exceeds the commonly discussed cut off levels for funding in the United Kingdom and United States of pound 30 000 and 50 000 dollars per QALY, respectively.

Cost-effectiveness analysis of augmentation therapy for severe alpha1-antitrypsin deficiency

A Markov-based decision model was created to assess the cost-effectiveness of augmentation therapy (Aug) for severe alpha1-antitrypsin deficiency, comparing strategies of: (1) no Aug, (2) Aug for life, and (3) Aug until FEV1 is below 35% predicted. A hypothetical cohort of 46-year-old patients with FEV1 49% predicted was followed over time using Monte Carlo simulation across five possible health states: (1) FEV1 50 to 79% predicted, (2) FEV1 35 to 49% predicted, (3) FEV1 below 35% predicted, (4) status-post-lung transplantation, and (5) dead. Treatment for life yielded 7.19 quality-adjusted life-years (QALYs) and cost 895,243 dollars. Treating until FEV1 is below 35% predicted cost 511,930 dollars and produced 6.64 QALYs. "No Aug" cost 92,091 dollars with 4.62 QALYs. The incremental cost-effectiveness ratio was 207,841 dollars/QALY for Aug until FEV1 is below 35% predicted and 312,511 dollars/QALY for the "Aug for life" strategy. In all sensitivity analyses, the incremental cost-effectiveness ratio for Aug for life exceeded 100,000 dollars. The cost of Aug needed to be reduced from 54,765 dollars to 4,900 dollars for the "Aug for life" strategy to be considered cost-effective. We conclude that, compared with other conventionally used health interventions, Aug is relatively less cost-effective. These results should encourage the development of more clinically and cost-effective therapies for alpha1-antitrypsin deficiency.

[Prognostic factors for mortality in out-of-hospital cardiorespiratory arrest]

BACKGROUND AND OBJECTIVE

Our purpose was to determine the prognostic factors of mortality among patients with cardiorespiratory arrest (CRA) assisted by 061 emergency teams in Andalusia.

PATIENTS AND METHOD

Retrospective observational study from January 1998 to December 1999 of 1950 cases of out-of-hospital CRA (OH-CRA) assisted by Andalusian 061 emergency teams (ETs). Independent (predictor) variables considered in the study were those defined in the Utstein style, after categorization. The dependent (outcome) variable was out-of-hospital mortality. A multivariate model was constructed using logistic regression to define the factors that, when considered together, predict mortality. The model was calibrated using the Hosmer-Lemeshow test. For the discrimination of the model, we calculated the area under the ROC curve.

RESULTS

The incidence of OH-CRA was 27/100,000. Among our population of 1950 patients, 24.95% (483) were admitted alive to hospital and 75.05% (1444) died in the out-of hospital setting; 1393 patients were male and 552 were female. The mean age was 61.3 28.4 years. The model revealed the following mortality prognostic factors: personnel performing cadiopulmonary resuscitation before ET arrival (healthcare/non-healthcare), presence of defibrillation, number of defibrillations, CRA site, general function categories before CRA, and cardiac massage within the first minute by ET.

CONCLUSIONS

In order to reduce the CRA-induced mortality in our setting, defibrillation and cardiac massage by ETs must be done without delay. It is fundamental to achieve greater health awareness and education among both the general population and the healthcare workers involved in the survival chain.

Cost-effectiveness of drotrecogin alfa (activated) in the treatment of severe sepsis

OBJECTIVE

To assess the cost-effectiveness of drotrecogin alfa (activated) therapy, which was recently shown to reduce mortality in severe sepsis.

DESIGN

Estimates of effectiveness and resource use were based on data collected prospectively as part of a multicenter international trial. Estimates of hospital costs were based on a subset of the patients treated in the United States (33% of all enrolled patients). Lifetime projections were modeled from published sources and tested in sensitivity analyses. Analyses were conducted from the United States societal perspective, limited to healthcare costs, and using a 3% annual discount rate.

SETTING

A total of 164 medical institutions in 11 countries.

PATIENTS

Adults > or = 18 yrs of age with severe sepsis

INTERVENTIONS

Eligible patients were randomly assigned to receive a 96-hr intravenous infusion of drotrecogin alfa (activated) at 24 microg/kg/hr (n = 850) or placebo (n = 840).

MEASUREMENTS AND MAIN RESULTS

Base Case: incremental short-term (days 1-28) healthcare costs per day-28 survivor; Panel on Cost-Effectiveness in Health and Medicine Reference Case: incremental lifetime healthcare costs per quality-adjusted life-year. Over the first 28 days (short-term Base Case), drotrecogin alfa (activated) increased the costs of care by $9,800 and survival by 0.061 lives saved per treated patient. Thus, drotrecogin alfa (activated) cost $160,000 per life saved (with 84.7% probability that ratio is <$250,000 per life saved). Projected to lifetime (lifetime Reference Case), drotrecogin alfa (activated) increased the costs of care by $16,000 and quality-adjusted survival by 0.33 quality-adjusted life-years per treated patient. Thus, drotrecogin alfa (activated) cost $48,800 per quality-adjusted life-year (with 82% probability that ratio is <$100,000 per quality-adjusted life-year). Estimates were generally robust to sensitivity analyses, although cost-effectiveness deteriorated to >$100,000 per quality-adjusted life-year if survivors lived <4.6 yrs on average. Drotrecogin alfa (activated) cost $27,400 per quality-adjusted life-year when limited to patients with an Acute Physiology and Chronic Health Evaluation II score > or = 25 and was cost-ineffective when limited to patients with a score <25.

CONCLUSIONS

Drotrecogin alfa has a cost-effectiveness profile similar to that of many well-accepted healthcare strategies and below commonly quoted thresholds.

Health system costs of in-hospital cardiac arrest

This paper reports on the health system resources used in the treatment of in-hospital cardiac arrests in a British district general hospital. The resources used in resuscitation attempts were recorded prospectively by observation of a convenience sample of 30 cardiac arrests. The post-resuscitation resource use by survivors was collected through a retrospective record review (n = 37) and by following survivor members in the prospective sample (n = 6). Financial data were used to translate resource use into costs (1999 prices). There was a non-significant trend for more resources to be used in daytime resuscitations than at night. Survivors had significantly fewer diagnostic tests during resuscitation than those who died (P = 0.004). Length of resuscitation attempt was positively and significantly related to resource use (P < 0.05). The average variable cost per resuscitation attempt (1999 prices) was 195.66 pounds sterling; 76.5% was for staff, and 13.1% for drugs and fluids. Emergency calls were attended by an average of 10.11 staff. The average fixed cost per resuscitation attempt was 928.81 pounds sterling; 12% for capital equipment and 73% for staff training. The average post-resuscitation costs attributable to the cardiac arrest of the 29 people surviving more than 24 h after cardio-pulmonary resuscitation (CPR) were estimated to be 1,589.72 pounds sterling. This is lower than other studies which estimated total costs of post-CPR lengths of stay. Reducing avoidable cardiac arrests would generate in-hospital savings in direct resuscitation care of survivors. Scope for reducing capital and training costs is discussed.

Cost effectiveness of aggressive care for patients with nontraumatic coma

OBJECTIVE

To estimate the cost effectiveness of aggressive care for patients with nontraumatic coma.

DESIGN

Cost-effectiveness analysis.

SETTING

Five academic medical centers.

PATIENTS

Patients with nontraumatic coma enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). Patients with reversible metabolic causes of coma such as diabetic ketoacidosis or uremia were excluded.

MEASUREMENTS

We calculated the incremental cost effectiveness of continuing aggressive care vs. withholding cardiopulmonary resuscitation and ventilatory support after day 3 of coma. We estimated life expectancy based on up to 4.6 yrs of follow-up. Utilities (quality-of-life weights) were estimated using time-tradeoff questions. Costs were based on hospital fiscal data and Medicare data. Separate analyses were conducted for two prognostic groups based on five risk factors assessed on day 3 of coma: age > or = 70 yrs, abnormal brainstem response, absent verbal response, absent withdrawal to pain, and serum creatinine > or = 132.6 micromol/L (1.5 mg/dL).

RESULTS

For the 596 patients studied, the median (25th, 75th percentile) age was 67 yrs (range, 55-77), and 52% were female. By 2 months after enrollment, 69% had died, 19% were severely disabled, 7% had survived without severe disability, and 4% had survived with unknown functional status. The incremental cost effectiveness of the more aggressive care strategy was $140,000 (1998 dollars) per quality-adjusted life year (QALY) for high-risk patients (3-5 risk factors, 93% 2-month mortality) and $87,000/QALY for low-risk patients (0-2 risk factors, 49% mortality). In sensitivity analyses, the incremental cost per QALY did not fall below $50,000/QALY, even with wide variation in our baseline estimates.

CONCLUSIONS

Continuing aggressive care after day 3 of nontraumatic coma is associated with a high cost per QALY gained, especially for patients at high risk for poor outcomes. Earlier decisions to withhold life-sustaining treatments for patients with very poor prognoses may yield considerable cost savings.

Geographical distribution of cardiac arrest in Nottinghamshire

BACKGROUND

to analyse the incidence of out-of-hospital cardiac arrest in Nottinghamshire; to ascertain its geographical distribution; and to determine whether the geography of coronary heart disease mortality and out-of-hospital cardiac arrest are the same.

METHODS AND RESULTS

population based, retrospective study in the County of Nottinghamshire with a total population of 993,914 in an area of 2183 km2 divided into 191 electoral areas. In the 4 years from 1 January, 1991 to 31 December, 1994, 1634 patients sustained a cardiac arrest attributed to a cardiac cause (International Classification of Diseases codes 390-414 and 420-429) and were attended by the Nottinghamshire Ambulance Service. The overall crude mean incidence rate of community cardiac arrest per electoral area was 40.2 per 100,000 population (range 0-121.2). Thirteen electoral areas, relatively deprived according to the Townsend score, had a significantly greater than expected incidence rate of cardiac arrest (median of 75.6/100,000 per electoral area; interquartile range (IQR) 65.3, 83.8). Twelve relatively affluent electoral areas had a significantly lower than expected incidence rate (median of 18.5/100,000 per area (IQR 13.0, 28.7). After adjusting for deprivation index, there were no differences in coronary heart disease (CHD) mortality and community cardiac arrest in urban and rural electoral areas. Apart from response times by ambulance crews, the events that follow the cardiac arrest such as bystander resuscitation, ventricular fibrillation found as the presenting rhythm and survival were similar in all electoral areas.

CONCLUSIONS

increasing level of deprivation is associated with areas of increased incidence of out-of-hospital cardiac arrest in Nottinghamshire, and the effect is apparently different from that on CHD mortality. There is scope for reducing incidence rates of community cardiac arrest and to introduce strategies to improve survival in areas identified as having high rates of community cardiac arrest.

Economics of end-of-life care in the intensive care unit

End-of life care is in need of improvement, yet little is known about the effectiveness or cost of various end-of-life therapies. Economic analyses are used to help make decisions between two or more therapies when resources are constrained. In this chapter, we review the various types of economic analyses, the costs of dying, and how healthcare reform has impacted these costs. Finally, we discuss the unique issues associated with cost-effectiveness studies of palliative therapy, with emphasis on the problem of calculating a cost-effectiveness ratio when there is no good measurement for valuing the quality of death. It is likely that methods for conducting a cost-effectiveness analyses for end-of-life care will need to evolve or alternative strategies such as cost-benefit analysis or distributive justice will be needed to inform resource allocation decisions. As the national debate about healthcare costs, access, and quality continues, we will increasingly turn to economic analyses to help make resource allocation decisions. Cost-effectiveness analysis will continue to be the most popular form of economic analysis because it combines the results (effectiveness of treatment) with the costs of achieving the results. We must be aware of the limitations of cost-effectiveness analyses and the need for value judgments when using cost-effectiveness analyses to inform healthcare decisions.

Neurological rehabilitation of severely disabled cardiac arrest survivors. Part I. Course of post-acute inpatient treatment

BACKGROUND

Some survivors of out-of-hospital cardiac arrest (CA) sustain anoxic brain injury. The aim of this study was to offer these patients a new treatment approach, to describe the course and outcome of rehabilitation, and to judge whether rehabilitation provided benefit.

METHODS

Twenty severely disabled patients (mean age 47.6 years, 17 M:3 F) were admitted for inpatient rehabilitation after sustaining anoxic brain damage secondary to CA. The multidisciplinary treatment approach aimed at orientation, communication, mobility, and self care. Function was assessed using Barthel index (BI) score. On discharge, placement and global outcome was noted. Medical charts of consecutive patients were reviewed retrospectively.

RESULTS

Inpatient rehabilitation lasted on for average 12 weeks. Improvement in function was slow with a median increase of 1.88 BI score per week. Patients achieved clinically significant functional improvement as measured by pre-post comparison of BI (P<0.001). On discharge, overall disability was mild in 2 (10%), moderate in 7 (35%), and severe in 11 (55%) patients.

CONCLUSION

Rehabilitation of selected CA survivors is appropriate, reducing the subsequent burden of care. Although in 55%, only minor dependence on care persisted, on a group level, the potential for rehabilitation was modest, and recovery curve was flat. Before admission, families should be given realistic information about the possible outcome, because independence was rarely achieved.

Regulatory and educational initiatives fail to promote discussions regarding end-of-life care

We conducted an observational cohort study to determine if hospital-based, reinforcing regulatory and educational interventions could encourage physicians to discuss end-of-life (EOL) care with their patients. Specifically, we measured the effect of (1) administrative prompts to encourage discussions about EOL care and (2) a mandatory educational seminar focusing on EOL issues. Study subjects were patients consecutively admitted to the medicine service who faced an anticipated 3-year mortality rate of at least 50%. The main study endpoint was the frequency of documented EOL discussions between physicians and patients. In the inception cohort of 184 patients, physicians discussed EOL care with 64 patients (34. 8%), and in the follow-up cohort of 121 patients, 41 individuals (33. 9%) had documented discussions regarding EOL issues (P = 0.90). Actual "Do Not Resuscitate"(DNR) orders were written for 53 patients (28.8%) in the inception cohort and for 33 persons (27.3%) in the follow-up cohort (P = 0.71). We conclude that enhanced, mutually reinforcing regulatory and educational efforts focusing on EOL care proved ineffectual at promoting either discussions about EOL issues or the use of DNR orders.

Serum S-100 and neuron-specific enolase for prediction of regaining consciousness after global cerebral ischemia

BACKGROUND AND PURPOSE

The aim of our study was to assess the use of S-100 protein (S-100) and neuron-specific enolase (NSE) in serum and cerebrospinal fluid (CSF) for the prediction of patients' regaining consciousness after acute global cerebral ischemia.

METHODS

Sixty-four unconscious patients were followed until the return of consciousness or until death/vegetative state. Serum and CSF samples for measurement of S-100 and NSE using an immunoradiometric assay technique were obtained 24 hours (serum) and 48 hours (CSF) after the acute event and correlated with patient outcome.

RESULTS

Values for serum S-100 protein, serum NSE, CSF S-100, and CSF NSE were significantly different in the 2 outcome groups. A serum S-100 value of >0.7 micrograms/L was found to be a predictor of not regaining consciousness, with a high positive predictive value (95%) and high specificity (96%).

CONCLUSIONS

S-100 protein used as serum marker 24 hours after acute global cerebral ischemia gives reliable and independent information on the outcome of the patient that is comparable or superior to that obtained with CSF markers. Therefore, S-100 may be a serum marker of brain cell damage useful for clinical assessment of these patients.

The role of futility judgments in improperly limiting the scope of clinical research

In medical research, the gathering and presenting of data can be limited in accordance with the futility judgments of the researchers. In that case, research results falling below the threshold of what the researchers deem beneficial would not to be reported in detail. As a result, the reported information would tend to be useful only to those who share the valuational assumptions of the researchers. Should this practice become entrenched, it would reduce public confidence in the medical establishment, aggravate factionalism within the research community, and unduly influence treatment decisions. I suggest alternative frameworks for measuring survival outcomes.

Treatment of out-of-hospital cardiac arrest in Ljubljana: outcome report according to the 'Utstein' style

We investigated survival of patients with out-of-hospital cardiac arrest in Ljubljana according to the 'Utstein' style. Ljubljana consists of urban, suburban and semi-rural communities which encompass an area of 1615 km2 with 397306 residents. The area is served by a single response emergency medical system and local family practitioners. Between January 1, 1995 and December 31, 1997 cardiac arrest was confirmed in 966 patients. Cardiopulmonary resuscitation was attempted in 454 patients (47%). Collapse of presumed cardiac etiology (337 patients) was either bystander-witnessed (89%), un-witnessed (9%) or EMS personnel-witnessed (2%). Asystole was documented in 55%, ventricular fibrillation or tachycardia in 36% and other non-perfusing rhythms in 9% of these patients. Lay-bystander basic life support was performed in 19%. Nineteen patients (5.6%) survived to hospital discharge and 12 of them were independent in daily life. The survival of subgroups with bystanders-witnessed collapse and bystanders-witnessed ventricular fibrillation was 6.4 and 13%, respectively. Collapse of non-cardiac etiology (117 patients) was preceded by either respiratory failure (41), politrauma (22), circulatory shock (19), cerebrovascular incident (ten), intoxication (nine), strangulation (seven), electrocution (five) or drowning (four patients). Only five patients (4.2%) survived to hospital discharge. Hospital treatment of patients after successful initial cardiopulmonary resuscitation was associated with high mortality and required considerable resources.

Should a cancer patient be resuscitated following an in-hospital cardiac arrest?

OBJECTIVE

Previous reports from general hospitals and cancer centers have identified the presence of malignancy as a poor prognostic indicator for successful cardiopulmonary resuscitation (CPR) for an in-hospital cardiac arrest. The purpose of this study was to evaluate the initial success of CPR as determined by return of spontaneous circulation (ROSC), patient survival to hospital discharge, and 1-year survival of this group as compared to previous studies in non-oncological centers. In addition, the charges incurred in caring for these patients were analyzed.

MATERIALS AND METHODS

All cardiac arrests occurring between 1 January 1993 and 31 December 1994 were identified from a centralized morbidity and mortality database and reviewed retrospectively. Cardiac arrest was defined as the absence of a palpable pulse and initiation of CPR. Patients suffering pure respiratory arrest or shock without loss of pulse were excluded. Age, gender, primary site of malignancy, initial and ultimate outcome, including Zubrod's functional status (ZFS), and total hospital charges following cardiac arrest were recorded. Computerized billing records were used to tabulate total charges.

RESULTS

83 cardiac arrests occurred during the study period (42 women, 41 men). Mean age was 56.2 years. Forty-two percent of the patients had hematologic malignancies, 19% lung, 15% gastrointestinal, 5% head and neck cancers and 19% other malignancies. Sixty-six percent of the patients had ROSC. Only eight (9.6%) patients survived to hospital discharge: three died within 6 weeks under hospice care, two died within 6 months of discharge and only three (3.6%) patients survived to 1 year. Functional status follow-up of these three patients revealed two with ZFS 1 and one with ZFS 2. Total hospital charges for these 83 patients were US$ 2,959,740.

CONCLUSIONS

Although ROSC after cardiac arrest in our patients was better than that reported for most series in general hospitals, their ultimate survival and hospital discharge was extremely poor.

Cardiopulmonary resuscitation: a review for clinicians

Attempts at cardiopulmonary resuscitation (CPR) date from antiquity, but it is only in the last 50 years that a scientifically-based methodology has been developed. External chest compressions is the standard method for managing circulatory arrest, however, numerous alterations of this technique have been proposed in attempts to improve outcome from CPR. Defibrillation is the single most important therapy for the management of ventricular fibrillation or pulseless ventricular tachycardia. Adrenergic agents used to improve myocardial and cerebral perfusion are also the subject of considerable investigation with new agents entering clinical study. This paper reviews the history, current techniques and pharmacotherapy as well as controversial issues in the management of patients with cardiac arrest.

Unexpected cardiac arrest after cardiac surgery: incidence, predisposing causes, and outcome of open chest cardiopulmonary resuscitation

STUDY OBJECTIVES

To assess the incidence of acute mechanical causes precipitating sudden cardiac arrest in cardiac surgery patients during the immediate postoperative period. In addition, we report the success rate of cardiopulmonary resuscitation (CPR) in which open-chest CPR was employed at an early stage of the resuscitation effort.

METHODS

Data on all cardiac surgical patients who suffered a sudden cardiac arrest during the first 24 h after surgery were collected prospectively. CPR consisted of conventional closed-chest CPR initially and was followed within 3 to 5 min, if needed, by open-chest CPR.

RESULTS

Of 3,982 patients undergoing cardiac surgery over a 30-month period, 29 patients (0.7%) had a sudden cardiac arrest. Of these, 13 patients (45%) were successfully resuscitated with closed-chest CPR, 14 (48%) with open-chest CPR, and 2 (7%) died despite closed- and open-chest CPR. Four CPR survivors died subsequently in the ICU, yielding an overall hospital discharge rate of 79%. Perioperative myocardial infarction was the underlying cause of sudden cardiac arrest in 14 patients (48%), and mechanical impediments to cardiac function (tamponade or graft malfunction) in another 8 (28%) patients; in the remaining 7 patients (24%), no underlying cause was found. The length of ICU stay was 6+/-1 (mean+/-SE) days. None of the patients developed wound infection and all were neurologically intact at hospital discharge.

CONCLUSION

Mechanical factors account for a substantial portion (28%) of causes of sudden cardiac arrest occurring in hemodynamically stable patients during the immediate postoperative period. This high incidence, in conjunction with the high survival rate achieved by open CPR, supports an early approach to open-chest CPR in this group of patients.