Poor outcome of on-site CPR in a multi-level geriatric facility: three and a half years experience at the Baycrest Centre for Geriatric Care

Cardiac Resuscitation Procedures in US Nursing Facilities: Time to Reevaluate the Standard of Care?

Although the use of automated external defibrillators (AEDs) in out-of-hospital cardiac arrest (OHCA) response has become the standard of care in many community settings over the past 20+ years, the adoption of AEDs in US nursing facilities is variable and the current number of facilities with AEDs is unknown. Recent research into the use of AEDs as part of cardiopulmonary resuscitation (CPR) procedures for nursing facility residents with sudden cardiac arrest demonstrates improved outcomes in the limited cohort with witnessed arrests, early bystander CPR, and an initial amenable rhythm, shocked with an AED before the arrival of Emergency Medical Services (EMS) personnel. This article reviews data about outcomes of CPR in older adults and nursing facility settings and proposes that standard procedures for CPR attempts in US nursing facilities should be reevaluated and continue to evolve, commensurate with the evidence and community standards.

Goals of Care Conversations in Long-Term Care during the First Wave of the COVID-19 Pandemic

Goals of care discussions typically focus on decision maker preference and underemphasize prognosis and outcomes related to frailty, resulting in poorly informed decisions. Our objective was to determine whether navigated care planning with nursing home residents or their decision makers changed care plans during the first wave of the COVID-19 pandemic. The MED-LTC virtual consultation service, led by internal medicine specialists, conducted care planning conversations that balanced information-giving/physician guidance with resident autonomy. Consultation included (1) the assessment of co-morbidities, frailty, health trajectory, and capacity; (2) in-depth discussion with decision makers about health status and expected outcomes; and (3) co-development of a care plan. Non-parametric tests and logistic regression determined the significance and factors associated with a change in care plan. Sixty-three residents received virtual consultations to review care goals. Consultation resulted in less aggressive care decisions for 52 residents (83%), while 10 (16%) remained the same. One resident escalated their care plan after a mistaken diagnosis of dementia was corrected. Pre-consultation, 50 residents would have accepted intubation compared to 9 post-consultation. The de-escalation of care plans was associated with dementia, COVID-19 positive status, and advanced frailty. We conclude that during the COVID-19 pandemic, a specialist-led consultation service for frail nursing home residents significantly influenced decisions towards less aggressive care.

Outcomes of Cardiac Arrest in Residential Care Homes for the Elderly in Hong Kong

OBJECTIVE

Studies done in the 1990's suggested nursing home residents with cardiac arrest had minimal chance of survival and resuscitation was not recommended. More recent studies showed opposing results. In Hong Kong, the proportion of elderly living in the residential care homes for the elderly is increasing. There is no study of out-of-hospital cardiac arrest outcomes in this population. This study aimed at evaluating the prognosis of out-of-hospital cardiac arrest occurring in the residential care homes for the elderly. It is hoped that the findings may inform the local emergency medical service concerning the issue of futility of resuscitating the residents with cardiac arrest in the residential care homes.

METHODS

This study was a retrospective analysis of a database of all patients aged 65 years or above with atraumatic out-of-hospital cardiac arrest and who were attended by the emergency medical service in a 12-month period. Data in the database were prospectively collected by the emergency medical service. The characteristics of patients and cardiac arrests, timeliness of the emergency medical service, and survival were analyzed. Comparison was made between elderly living in and not living in the residential care homes. Predictors of survival were evaluated with logistic regression.

RESULTS

3919 patients aged ≥ 65 years were analyzed. There were 1506 cases of cardiac arrest occurring in the residential care homes for the elderly. Resuscitation was discontinued at the emergency department in over 70% of these cases. The survival to hospital admission rate and the 30-day survival rate were 9.6% and 0.3% respectively. Both were lower than patients not residing in the residential care homes. Younger age, witnessed arrest, bystander defibrillation, and shorter call to ED interval were associated with higher chance of surviving to hospital admission.

CONCLUSION

Elderly suffering from cardiac arrest in residential care homes had a poor chance of survival. Except age, witnessed arrest, bystander defibrillation, and call to ED interval are modifiable predictors of survival. It is inappropriate to declare that resuscitating elderly in residential care homes is futile unless those factors have been fully addressed.

Do-Not-Hospitalize Orders in Nursing Homes: "Call the Family Instead of Calling the Ambulance"

OBJECTIVES

To determine how do-not-hospitalize (DNH) orders are interpreted and used in nursing homes (NHs) once they are in place.

DESIGN

Qualitative study using in-depth semi-structured interviews performed from December 2013 to April 2014.

SETTING

Eight skilled nursing facilities in Connecticut that ranked in the top 10% or bottom 10% in hospitalization rates from 2008 to 2010.

PARTICIPANTS

Nursing facility staff members (N = 31).

MEASUREMENTS

A multidisciplinary team performed qualitative content analysis. The constant comparative method was used to develop a coding structure and identify themes.

RESULTS

DNH orders were uncommon at low- and high-hospitalizing facilities. Participants reported that they did not interpret these orders literally. A DNH order was not a prohibition against hospitalization but was understood to have a variety of exceptions. These orders functioned primarily as a signal that hospitalization should be questioned and discussed with the family when an acute event occurred.

CONCLUSION

In-the-moment discussions about hospitalization are still necessary even when a DNH order is in place. Work to reduce potentially burdensome NH-hospital transfers needs to focus not just on eliciting preferences in advance, but also on preparing residents and their families to make the best decisions about hospitalization when the time comes.

Terminal hospitalizations of nursing home residents: does facility increasing the rate of do not resuscitate orders reduce them?

CONTEXT

Terminal hospitalizations are costly and often avoidable with appropriate advance care planning.

OBJECTIVES

This study examined the association between advance care planning, as measured by facility rate of do not resuscitate (DNR) orders in U.S. nursing homes (NHs) and changes in terminal hospitalization rates.

METHODS

Retrospective cohort study of the changing prevalence of DNR orders in U.S. NHs. Using a fixed effect multivariate model, we examined whether increasing facility rate of DNR orders correlates with reductions in terminal hospitalizations in the last week of life, controlling for changes in facility characteristics (staffing, use of NP/PA, case mix of nursing residents, admission volume, racial composition, payer mix).

RESULTS

The average facility rate of terminal hospitalizations was 15.5%, fluctuating between 1999 (15.0%) and 2007 (14.8%). NHs starting with low rates of DNR orders that increased their rates had fewer terminal hospital admissions in 2007 (11.2%) than facilities with continuously low DNR usage. Even after applying a multivariate fixed effect model, the effect of changes in facility DNR order rate on terminal hospitalization was -0.056 (95% confidence interval: -0.061, -0.050), indicating that for every 10% increase in DNR orders there was 0.56% decrease in terminal hospitalizations. This rate can be compared with the increase of 0.70% in the terminal hospitalization rate when an NH became disproportionately dependent on Medicaid funding or the 0.40% decrease in terminal hospitalization rate associated with adding a nurse practitioner to the clinical staff complement.

CONCLUSION

NHs that changed their culture of decision making by increasing their facility rate of DNR orders decreased their rate of terminal hospitalizations.

A New Health Care Directive for Long-Term Care Elderly based on Personal Values of Life

Determining the appropriate intensity of investigation and treatment for individual elderly patients in long-term care settings can present a significant challenge to physicians, especially when patients are incompetent to decide for themselves. However, respecting established intervention levels may represent an even greater challenge, given the realities of coverage by on-call physicians. This paper describes a new Intervention Level Scale for competent as well as incompetent long-term care elderly, and its validation as a communication tool between attending and on-call physicians. Specifically studied were (a) concordance of interventions, (b) whether prior knowledge of an intervention level by an on-call physician was considered useful, (c) applicability of the scale in different institutions and (d) necessity of physician training for optimal use. The scale's uniqueness resides in the fact that it is based on personal values of life, rather than institutional resources, and it incorporates directives on family contact.

Prevalence and related factors of do-not-resuscitate directives among nursing home residents in Taiwan

OBJECTIVES

To report the prevalence of Do-Not-Resuscitate (DNR) directives and to explore the factors associated with the presence of DNR directives among nursing home residents in Taiwan.

DESIGN

A cross-sectional, correlation study.

SETTING

Seven nursing homes in southern Taiwan.

PARTICIPANTS

Nursing home residents and their family surrogates.

MEASUREMENTS

Data were collected using chart abstraction and a questionnaire survey. We used multivariate logistic regression to analyze the associations between resident, family surrogate, and facility characteristics and the presence of DNR directives.

RESULTS

Among the 201 nursing home residents, 33 (16.4%) had DNR directives and 91% of the directives had been put in place by family surrogates. Our data revealed that resident's age (OR = 1.06, 95% CI = 1.01-1.12), cognitive function score (OR = 0.91, 95% CI = 0.85-0.97), prior DNR discussion between physician and family surrogate (OR = 4.09, 95% CI = 1.53-10.96), and nursing home with DNR policy (OR = 17.71, 95% CI = 5.87-53.46) were independently and associated with the presence of a DNR directive.

CONCLUSIONS

The prevalence of DNR directives among Taiwanese nursing home residents was lower than that in other countries. Our results point out the lack of DNR policy in most Taiwanese nursing homes and highlight the need for policy makers to implement further regulations. Meanwhile, education about advance directives is warranted to increase public and professional awareness and to facilitate empowerment of the increasing number of frail elderly nursing home residents in Taiwan.

Lack of Early Defibrillation Capability and Automated External Defibrillators in Nursing Homes

OBJECTIVE

To determine the availability of early defibrillation and automated external defibrillators in nursing homes in selected cities.

DESIGN

A standardized telephone survey was conducted of all skilled nursing facilities to characterize early defibrillation capabilities.

SETTING

The study involved nursing homes in Philadelphia, Omaha, Seattle, and Boston.

PARTICIPANTS

All skilled nursing facilities not physically attached to hospitals in the selected cities based on listings from the Centers for Medicare and Medicaid Services as of January 2004.

MEASUREMENTS

Each site was queried as to whether or not they had an automated external defibrillator (AED), if they were physically freestanding facilities, if a manual defibrillator was present, and if staff were present 24 hours a day to use the defibrillator. Early defibrillation was defined as the presence of either a manual defibrillator or AED in addition to 24-hour trained staff availability.

RESULTS

There were 126 nursing homes identified from the Medicare listing and 81% (102) responded to our phone survey. After exclusion of non-freestanding facilities, 90 nursing homes (71.4%) were available for analysis. Overall, 16.7% (95% CI 8.8-24.5) of nursing homes reported early defibrillation capabilities via manual defibrillator or AEDs; 6.7% (95% CI 1.4-11.9) of nursing homes reported AEDs; 10.0% (95% CI 3.7-16.3) of nursing homes reported manual defibrillators. Nursing homes in Seattle had a higher rate of early defibrillation capability than the other 3 cities.

CONCLUSION

Despite the fact that nursing homes have been identified as locations with multiple cardiac arrests, the early defibrillation capabilities and prevalence of AEDs in this setting remains low. AEDs may play a role in improving survival from cardiac arrest in nursing homes. The placement of AEDs in nursing homes needs further consideration and study.

Resuscitation of the Elderly

The changing demographics of America's population over the past couple of decades have propelled geriatric medicine into the fore-front. Due to this, emergency medicine physicians will face numerous challenges managing an increasing number of critically ill elderly patients. This article will focus on success of resuscitation in this population, important pathophysiologic changes that occur with aging, as well as ethical considerations in end-of-life care.

Termination of resuscitation: the art of clinical decision making

Despite all of the progress in reanimating patients in cardiac arrest over the last half century, resuscitation attempts usually fail to restore spontaneous circulation. Thus, the most common of all resuscitation decisions after initiation remains the decision to stop. An entire library of research and guidelines for terminating resuscitative efforts has been developed in the past decade. However, this most central decision is often left open to chance, provider preference, family wishes, futility judgments, and resource concerns-a host of subjective considerations at the bedside and beyond. This article sheds light on these considerations, acknowledging the pivotal role that resuscitation science and guidelines can play in the multifactorial decision to discontinue resuscitative efforts.

Resuscitation decision index: a new approach to decision-making in prehospital CPR

Retrospective and prospective studies have been undertaken to assess physicians' practice-patterns by studying cardiopulmonary resuscitation (CPR) case summaries. Most summaries reveal similar influences by the physician, patient and situation-related variables on the patterns of resuscitation. The initiation of resuscitation efforts is addressed frequently, but, very few studies discuss the topic of termination of resuscitation. Prehospital emergencies are addressed very rarely. The objective of this study was to introduce a new methodological approach towards initiation and termination of resuscitation efforts in prehospital situations. The subject studied were the physicians' decisions concerning initiation/withholding, termination/withdrawal and the resulting early survival rates. The result is termed the "Resuscitation decision index" (RDI). The "RDI" could be a tool allowing comparisons on a quantitative level, between different EMS systems or disciplines and giving an insight into the decision process. The "RDI" can enhance audit of resuscitation. The process of decision-making can be used to help future theoretical decision-making strategies.

Automated external defibrillators in long-term care facilities are cost-effective

OBJECTIVE

To assess the cost per life saved of equipping long-term care facilities (LTCFs) with automated external defibrillators (AEDs).

METHODS

Outcomes for cardiac arrests within LTCFs were retrieved for 1994 to 1997 from a comprehensive out-of-hospital cardiac arrest registry in a mid-sized U.S. city. The total expense for all LTCFs to obtain and maintain AEDs and to educate and maintain staff skill was estimated for a theoretical four-year period. The cost per life saved to the time of hospital discharge was calculated based on an estimated survival rate of 25% of patients found in ventricular fibrillation (VF) with placement of AEDs in LTCFs. A sensitivity analysis that varied survival rates and costs was conducted.

RESULTS

Over four years, there were 160 actual arrests in 43 LTCFs, with a hospital discharge survival rate of 2/160. Twenty of 160 presented to emergency medical services in VF. Training costs for four years were $1,225 per AED. Purchase and maintenance expenses for one AED over four years were $3,941. Placing AEDs in LTCFs would cost $87,837 per life saved if 25% of patients found in VF survived to hospital discharge. Sensitivity analysis using survival rates of 5%, 15%, and 35% established the cost per life saved at $439,184, $146,395, and $62,741, respectively. When costs were calculated at one-half and twice the estimated expense, the cost per life saved was $43,918 and $175,674, respectively.

CONCLUSION

Placing AEDs in LTCFs is cost-effective at $87,837 per life saved, if a hospital discharge survival rate of 25% of patients in VF can be achieved.

Cardiopulmonary resuscitation in the elderly. Beneficial or an exercise in futility?

Sudden cardiac death is one of the leading causes of death and a major public health problem that particularly affects the elderly. Sudden cardiac death may be a terminal event after a prolonged debilitating and painful illness, or it may occur following many years of symptoms related to a cardiac disorder; however, in many elderly persons, the cardiac arrest may be the first manifestation of cardiac disease in a supposedly healthy and physically active person. Whether cardiopulmonary resuscitation should be performed in elderly patients who sustain cardiac arrest is a significant issue confronting the medical profession and the general public. Several questions must be answered when evaluating the decision of whether or not to perform cardiopulmonary resuscitation on an elderly patient.

Emergency department use by nursing home residents

STUDY OBJECTIVE

To describe a community's experience with the use of emergency department services by nursing home residents.

METHODS

We performed a retrospective chart review of a population-based cohort of nursing home residents in an urban county in central Georgia with 10 nursing homes (1,300 beds) and 4 hospital-based EDs. All ED visits by nursing home residents during 1995 were analyzed. Demographic data, timing of the visit, chief complaint, tests and treatments, disposition, and financial charges were recorded. Further, we calculated the number of ED visits per 100 nursing home patient-years.

RESULTS

A total of 873 nursing home residents made 1,488 ED visits. Mean age was 76.0 years; 66.4% were female, and 55.2% were white. Of the transfers, 42.9% occurred during regular working hours. The most common chief complaints were respiratory symptoms (14.4%), altered mental status (10.1%), gastrointestinal symptoms (9.9%), and falls (8.2%); 101 patients (6.8%) were transferred for malfunction of a gastrostomy tube. The most common laboratory tests were complete blood cell count (69.5%), chest radiograph (52.0%), electrocardiogram (45.0%), urinalysis (42.7%), and determination of electrolytes (42.7%). A total of 42.4% of the ED visits led to admission to the hospital. From the 10 nursing homes, there were 110 ED visits per 100 patient-years. A 3.5-fold difference in ED use among these nursing homes could not be explained by age, gender, or other factors. The average .charge per ED visit was $1,239.

CONCLUSION

Elders living in nursing homes are frequently transferred to EDs for costly medical evaluations, and more than 40% of such visits lead to admission to the hospital.

Marginally effective medical care: ethical analysis of issues in cardiopulmonary resuscitation (CPR)

Outcomes from cardiopulmonary resuscitation (CPR) remain distressingly poor. Overuse of CPR is attributable to unrealistic expectations, unintended consequences of existing policies and failure to honour patient refusal of CPR. We analyzed the CPR outcomes literature using the bioethical principles of beneficence, non-maleficence, autonomy and justice and developed a proposal for selective use of CPR. Beneficence supports use of CPR when most effective. Non-maleficence argues against performing CPR when the outcomes are harmful or usage inappropriate. Additionally, policies which usurp good clinical judgment and moral responsibility, thereby contributing to inappropriate CPR usage, should be considered maleficent. Autonomy restricts CPR use when refused but cannot create a right to CPR. Justice requires that we define which medical interventions contribute sufficiently to health and happiness that they should be made universally available. This ordering is necessary whether one believes in the utilitarian standard or wishes medical care to be universally available on fairness grounds. Low-yield CPR fails justice criteria. Cardiopulmonary resuscitation should be performed when justified by the extensive outcomes literature; not performed when not desired by the patient or not indicated; and performed infrequently when relatively contraindicated.

Outcomes of cardiac arrest in the nursing home: destiny or futility? [see comment]

OBJECTIVE

To compare EMS system characteristics and outcomes between nursing home (NH) patients and out-of-hospital cardiac arrest (OHCA) patients whose arrests occurred in a residence (home).

DESIGN

Prospective cohort study reviewing OHCA from July 1989 to December 1993. Variables were age, witnessed arrest, response intervals, automated external defibrillator (AED) use, and arrest rhythms. Outcomes were hospital admission and discharge. Pearson chi-square was used for analysis.

SETTING

Suburban EMS system.

SUBJECTS

Patients > or = 19 years old with arrest of presumed cardiac cause, with locations at home or at a NH.

RESULTS

2,348 total arrests were complete for analysis, 182 at a NH and 2,166 at home. BLS and ALS response intervals were shorter for the NH patients. The NH patients were more likely to receive CPR on collapse, were older (73.1 vs 67.5 years, p < 0.001), were less likely to have had an AED used (9.9% vs 30.0%, p < 0.001), and were more likely to have an arrest bradyasystolic rhythm (74.7% vs 51.5%, p < 0.001). They were less likely to survive to hospital admission (10.4% vs 18.5%, p < 0.006) and discharge (0.0% vs 5.6%, p < 0.001).

CONCLUSION

During this four-and-a-half-year study period, no NH patient survived, even though % CPR was increased. Arrest rhythm is an important factor in this finding. EMS initial care for ventricular tachycardia/fibrillation NH patients, with less application of AEDs, was identified. This different response may adversely contribute to dismal NH outcome.

Cardiopulmonary resuscitation policies in long-term care facilities

OBJECTIVES

To describe CPR policies and the procedures for discussing CPR policies of Wisconsin long-term care facilities.

DESIGN

Mail survey and telephone interview.

MEASUREMENTS

Information about CPR policy, how policy is disclosed to residents and by whom, emergency medical technician team (EMT) response time, and number of CPR attempts during 1993.

RESULTS

The 1994 survey response rate was 85% (346/ 404 facilities). Four percent of responding facilities maintain a policy of never initiating CPR. Another 23% never initiate CPR but would call an EMT. Lack of efficacy was the usual basis for policies never initiating CPR. About 15% of facilities would initiate CPR only on residents who had previously indicated a preference. On individuals who had not made an advanced directive decision, 57% of facilities would initiate CPR in the event of an arrest. Almost 30% of facilities offering CPR would initiate CPR on unwitnessed arrests. Approximately 51% of all facilities assigned a social worker alone to discuss CPR policy and preference, whereas 12.5% assigned a physician alone or as part of a team. During 1993, an estimated 118 attempts at CPR were reported for 172 facilities with a total of 19,596 licensed beds, for a frequency of one CPR attempt per 166 beds per year.

CONCLUSIONS

Poor efficacy in this population was the main reason given for policies of never initiating CPR. Specific factors relating to CPR efficacy, such as EMT response time and ease of maintaining trained staff, were not major influences. Almost 30% of facilities offering CPR would perform it in unwitnessed situations, despite unlikely success. Many decisions about CPR may not be fully informed as nurses and physicians are not often assigned to discuss advance directives with residents or surrogates. Utilization of CPR in nursing homes offering resuscitation is low.

Program of All-inclusive Care for the Elderly (PACE): an innovative model of integrated geriatric care and financing

OBJECTIVES

The Program of All-inclusive Care for the Elderly (PACE) is a long-term care delivery and financing innovation. A major goal of PACE is prevention of unnecessary use of hospital and nursing home care.

SETTING

PACE serves enrollees in day centers and clinics, their homes, hospitals and nursing homes. Beginning at On Lok in San Francisco, the PACE model has been successfully replicated across the country. In 1995, PACE was fully operational in 11 cities in nine states.

PARTICIPANTS

To enroll in PACE, a person must be 55 years of age or older, be certified by the state as eligible for care in a nursing home and live in the program's defined geographical catchment area. PACE participants are ethnically diverse. In 1995, the average PACE enrollee was 80.0 years old and had an average of 7.8 medical conditions and 2.7 dependencies in Activities of Daily Living. A significant number have bladder incontinence (55%). Many enrollees (39%) live alone in the community, and 14% have no means of informal support.

INTERVENTION

Medicare and Medicaid waivers allow delivery of services beyond the usual Medicare and Medicaid benefits. The PACE service delivery system is comprehensive, uses an interdisciplinary team for care management, and integrates primary and specialty medical care. PACE receives monthly capitation payments from Medicare and Medicaid. Patients ineligible for Medicaid pay privately.

RESULTS

Outcomes of PACE programs have been positive. There has been steady census growth, good consumer satisfaction, reduction in use of institutional care, controlled utilization of medical services, and cost savings to public and private payers of care, including Medicare and Medicaid. However, starting up a PACE program requires substantial time and capital, and the model has not yet attracted large numbers of older middle income adults.

CONCLUSION

The growing number of older people in the United States challenges healthcare providers and policy makers alike to provide high quality care in an environment of shrinking resources. The PACE model's comprehensiveness of health and social services, its cost-effective coordinated system of care delivery, and its method of integrated financing have wide applicability and appeal.

Limiting treatment in nursing homes: knowledge and attitudes of nursing home medical directors

OBJECTIVE

To determine nursing home medical directors' knowledge about cardiopulmonary resuscitation outcome and their support of treatment limitation requests and policies.

DESIGN

Mailed questionnaire, followed by telephone interview.

PARTICIPANTS

Forty-six medical directors of 70 community nursing homes in Harris County, Texas.

MEASUREMENTS

Medical directors were asked to estimate the CPR survival rate to discharge of all nursing home residents and that of two case scenarios. They were asked to indicate on a Likert scale their support for mandatory Do-Not-Resuscitate orders and for requests by nursing home patients to withhold other life support measures.

RESULTS

Responses were received from 33 directors. Overall CPR survival rate of older nursing home residents after cardiac arrest was thought to be 10.7%. The average CPR survival rate for healthy older people with witnessed arrests was believed to be 13.8%. The perceived rate for unwitnessed arrests in terminal patients was 4.6%, significantly lower than estimates for healthy older people (P = .003) and estimates of the overall survival rate (P = .02). Medical directors were split regarding mandatory Do-Not-Resuscitate orders for patients in vegetative states, with terminal illness, with an unwitnessed arrest, or in those older than 90 years of age. Mandatory use of Do-Not-Resuscitate orders for all nursing home residents was strongly opposed. Assuming a 2% survival rate did not significantly influence medical directors' opinions about mandatory DNR orders in these groups. Medical directors were more willing to support requests by stable nursing home residents to withhold resuscitation, mechanical ventilation, or hospitalization than requests to withhold antibiotics, intravenous fluids, or tube feedings (P < .005). The majority of medical directors were willing to withhold all such measures for terminal patients.

CONCLUSIONS

Health care professionals who are responsible for educating patients about the efficacy of cardiopulmonary resuscitation in nursing homes overestimate its benefit and may benefit from further education about its outcome. Although mandatory Do-Not-Resuscitate orders were favored for terminal or vegetative patients, medical directors are not supportive of such orders across the board. Medical directors are more willing to honor requests for treatment limitation by terminal patients than others.

Older nursing home residents have a cardiac arrest survival rate similar to that of older persons living in the community

OBJECTIVE

To determine the survival rates of older nursing home residents after cardiopulmonary resuscitation (CPR) and to compare it with that of older persons who experienced cardiac arrest in an outpatient setting. To identify patient characteristics, arrest characteristics, and effort characteristics that are associated with higher survival rates.

DESIGN

Retrospective review of emergency medical service charts and hospital medical records of a cohort of older nursing home residents (n = 114) after cardiopulmonary resuscitation and a matched cohort of community-residing older persons (n = 228) matched on age, gender, and year of cardiac arrest.

SETTING

A large metropolitan city served by a tiered emergency medical service.

MEASUREMENTS

Independent variables related to patient, cardiac arrest, and resuscitation effort characteristics. Dependent variables were defined as immediate survival after cardiopulmonary resuscitation and survival status at discharge.

RESULTS

The mean age of nursing home residents was 80.3 years; 62.3% were females. The majority of cardiac arrests for both groups were unwitnessed (67%) and had agonal rhythms (asystole and electromechanical dissociation). Emergency medical service efforts were similar for the two cohorts. Among nursing home residents, 26.3% had a return of blood pressure for more than 5 minutes, 70.2% were pronounced dead in the emergency room, and 10.5% were discharged from hospitals alive. In the matched community-residing subjects, 22.7% had a return of blood pressure, 78.1% were pronounced dead in the emergency room, and 9.2% were discharged alive. Between-group comparisons of these variables revealed no significant differences even though our sample size was adequate.

CONCLUSIONS

We conclude that survival after cardiac arrest of older persons residing in nursing homes is low; however, with an appropriate CPR/DNR selection process and an effective emergency medical system, survival of certain groups of nursing home residents following cardiac arrest could be comparable to that of community residing older persons. Despite the reasonably good survival rates for older persons seen above, our analyses indicated that patients who have unwitnessed arrests are not likely to survive to discharge and that patients with initial rhythms such as asystole or electromechanical dissociation rarely survive. These data suggest that patients who have an unwitnessed arrest in the nursing home should not receive resuscitation attempts, and in those patients for whom paramedics are called, resuscitation efforts should not proceed any further if their original rhythm is asystole or electromechanical dissociation. Thus, modification in nursing home policies regarding CPR efforts is needed.

Cardiopulmonary resuscitation in elderly patients hospitalized in the 1990s: a favorable outcome

OBJECTIVE

To compare the clinical characteristics and survival of elderly and younger hospitalized patients who sustain cardiac arrest and receive cardiopulmonary resuscitation (CPR) in the 1990's and to assess predictors of survival.

DESIGN

Retrospective survey of cardiac arrest database and hospital charts, plus telephone follow-up.

SETTING

450-bed acute care teaching hospital.

STUDY POPULATION

Seventy-eight hospitalized patients 70 years or older and 73 hospitalized patients under 70 years of age.

MEASUREMENTS

Survey of cardiac arrest data base, hospital charts, and telephonic follow-up to allow (1) comparison of clinical characteristics, survival, and long-term follow-up between two age groups and (2) univariate and multivariate analysis of predictors of mortality.

MAIN RESULTS

Pre-arrest clinical characteristics were not significantly different between the age groups. Prior to arrest the majority of patients were functionally active, and over one-third were hospitalized for acute coronary artery syndromes. In approximately 85% of the patients, the arrest was witnessed, and 70% of the patients had their cardiac rhythm monitored at onset of the arrest. Survival was not significantly different between the age groups; 26% of the total 151 patients were discharged. No significant difference was noted in pre-post arrest functional status of survivors. Survival at 1, 2, and 3 years in elderly and younger survivors was 86% versus 80%, 76% versus 67%, and 71% versus 61%, respectively. Multivariate analysis identified the presence of coronary artery disease, admission systolic blood pressure, and functional level to be independent pre-arrest predictors of mortality. At the time of the arrest, the initial cardiac rhythm and duration of CPR were found to be independent predictors of mortality.

CONCLUSIONS

Elderly patients hospitalized in the 1990's who receive CPR have outcomes similar to younger patients who receive CPR. The favorable outcome in the elderly patients may reflect patient selection: the majority of our patients were functionally active prior to hospitalization, without multiple serious illnesses; many were hospitalized for acute coronary artery syndromes; and, in most cases, the arrest was witnessed with the patient's cardiac rhythm monitored at onset of the arrest.