Utilization of cardiopulmonary resuscitation in nursing homes in one community: rates and nursing home characteristics

Advance care planning for residents in aged care facilities: what is best practice and how can evidence-based guidelines be implemented?

Background  Advance care planning in a residential care setting aims to assist residents to make decisions about future healthcare and to improve end-of-life care through medical and care staff knowing and respecting the wishes of the resident. The process enables individuals and others who are important to them, to reflect on what is important to the resident including their beliefs/values and preferences about care when they are dying. This paper describes a project conducted as part of the Joanna Briggs Institute Clinical Aged Care Fellowship Program implemented at the Manningham Centre in metropolitan Melbourne in a unit providing services for 46 low and high care residents. Objectives  The objectives of the study were to document implementation of best practice in advance care planning in a residential aged care facility using a cycle of audit, feedback and re-audit cycle audit with a clinical audit software program, the Practical Application of Clinical Evidence System. The evidence-based guidelines found in 'Guidelines for a Palliative Approach in Residential Aged Care' were used to inform the process of clinical practice review and to develop a program to implement advance care planning. Results  The pre-implementation audit results showed that advance care planning practice was not based on high level evidence as initial compliance with five audit criteria was 0%. The barriers to implementation that became apparent during the feedback stage included the challenge of creating a culture where advance care planning policy, protocols and guidelines could be implemented, and advance care planning discussions held, by adequately prepared health professionals and carers. Opportunities were made to equip the resident to discuss their wishes with family, friends and healthcare staff. Some residents made the decision to take steps to formally document those wishes and/or appoint a Medical Enduring Power of Attorney to act on behalf of the resident when they are unable to communicate wishes. The post-implementation audit showed a clear improvement as compliance ranged from 15-100% for the five audit criteria. Strong leadership by the project team was effective in engaging staff in this quality improvement program. Conclusion  The outcomes of the project were extremely positive and demonstrate a genuine improvement in practice. All audit criteria indicate that the Manningham Centre is now positively working towards improved practice based on the best available evidence. It is hoped that as the expertise developed during this project is shared, other areas of gerontological practice will be similarly improved and more facilities caring for the older person will embrace evidence-based practice.

Cardiac Arrests in Skilled Nursing Facilities: Continuing Room for Improvement?

OBJECTIVES

To characterize the care received by skilled nursing facility (SNF/NF) patients suffering cardiac arrest and to evaluate the outcome of SNF/NF patients experiencing cardiac arrest.

DESIGN

A retrospective analysis of an existing cardiac arrest registry to characterize SNF/NF cardiac arrest patients and to compare them to community-dwelling cardiac arrest patients was performed.

SETTING

The study took place in Rochester, NY, an urban city in upstate New York with approximately 220,000 residents.

PARTICIPANTS

All patients for whom emergency medical services (EMS) assistance was requested via the 911 system and who were treated for cardiac arrest between January 1998 and December 2001 were included.

MEASUREMENTS

Demographic characteristics such as age, gender, race; clinical characteristics and interventions such as cardiopulmonary resuscitation (CPR), defibrillation, initial cardiac rhythm, and call response interval; outcomes measures such as return of spontaneous circulation and 1-year survival were obtained.

RESULTS

Forty-two (8%) of cardiac arrest patients resided in an SNF/NF. Sixteen (38%) of the events were witnessed arrests. Only 28 (67%) patients received CPR and none were defibrillated prior to EMS arrival. One (2%) patient was alive 1 year after the event, a survival rate similar to the community-dwelling population (5%).

CONCLUSION

SNF/NF patients suffering cardiac arrest often did not receive CPR or defibrillation while awaiting EMS arrival. SNF/NF patients suffering cardiac arrest have a very low survival rate, similar to the community-dwelling population. The impact of not providing CPR and defibrillation on the survival rate is unclear, but needs to be evaluated prior to any decisions regarding the medical futility of resuscitating SNF/NF patients.

Cardiac Arrests in Skilled Nursing Facilities: Continuing Room for Improvement?

OBJECTIVES

To characterize the care received by skilled nursing facility (SNF/NF) patients suffering cardiac arrest and to evaluate the outcome of SNF/NF patients experiencing cardiac arrest.

DESIGN

A retrospective analysis of an existing cardiac arrest registry to characterize SNF/NF cardiac arrest patients and to compare them to community-dwelling cardiac arrest patients was performed.

SETTING

The study took place in Rochester, NY, an urban city in upstate New York with approximately 220,000 residents.

PARTICIPANTS

All patients for whom emergency medical services (EMS) assistance was requested via the 911 system and who were treated for cardiac arrest between January 1998 and December 2001 were included.

MEASUREMENTS

Demographic characteristics such as age, gender, race; clinical characteristics and interventions such as cardiopulmonary resuscitation (CPR), defibrillation, initial cardiac rhythm, and call response interval; outcomes measures such as return of spontaneous circulation and 1-year survival were obtained.

RESULTS

Forty-two (8%) of cardiac arrest patients resided in an SNF/NF. Sixteen (38%) of the events were witnessed arrests. Only 28 (67%) patients received CPR and none were defibrillated prior to EMS arrival. One (2%) patient was alive 1 year after the event, a survival rate similar to the community-dwelling population (5%).

CONCLUSION

SNF/NF patients suffering cardiac arrest often did not receive CPR or defibrillation while awaiting EMS arrival. SNF/NF patients suffering cardiac arrest have a very low survival rate, similar to the community-dwelling population. The impact of not providing CPR and defibrillation on the survival rate is unclear, but needs to be evaluated prior to any decisions regarding the medical futility of resuscitating SNF/NF patients.

Advance care planning in residential care

BACKGROUND

To provide optimal care for our ageing population, some form of advance care planning (ACP) is essential. Overseas data suggest that the process of ACP and the use of advance care directives (ACD) is suboptimal in residential care institutions. By comparison there are few Australian data.

AIM

To study the process of ACP and the prevalence of ACD in residential care.

METHODS

Cross-sectional study using a questionnaire in the Hunter area, NSW, Australia.

RESULTS

Very low levels of formal advance directives were found (available for only 0.2%). Only 1.1% of residents had 'no-CPR' orders documented in the medical record, while 5.6% had a formal guardian and 2.8% had an enduring guardian. Informal processes of advance planning were much more prevalent. Sixty-five per cent had a 'person responsible' recorded to make decisions for them while in 13% of cases, there was 'staff consensus' as to the optimal care for the patient. However, in 10.6% there was no clear process for medical decision making identified.

CONCLUSIONS

Advanced directives are infrequently used in residential care. Further qualitative and quantitative studies are warranted to explore current processes of decision making.

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.

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.

Code status decision-making in a nursing home population: processes and outcomes

OBJECTIVES

To examine the clinical utility of prehospital code status discussions in a nursing home (NH) setting and the health care outcomes of the decisions made. Also to identify patient factors and other variables associated with these decisions.

DESIGN

Retrospective uncontrolled observational study carried out through record review.

SETTING

A single skilled-level teaching NH and its affiliated university hospital.

PATIENTS

All of the 350 individuals who resided at the NH during a 2-year period.

MAIN RESULTS

Code status decisions were routinely sought through discussion involving primary care physician/social worker teams and residents or surrogates of demented patients. Choices were made for 80% of the NH residents, most (73%) by surrogates and most (80%) for do-not-resuscitate (DNR) orders, usually within 10 weeks of NH admission. Neither short-term measures of NH care intensity nor hospital use changed after a DNR decision. Most (80%) hospital transfer records included code status documentation. At the NH, both the likelihood of decisions and their directions were associated with involvement by specific physician/social worker teams. Additionally, a dementia diagnosis, white race, and older age were associated with a nursing home DNR decision. At the hospital, a DNR order was associated with white race, the presence of nursing home DNR documentation in the transfer records, hospital attending care by certain NH physicians, and a terminal hospital stay. Hospital inpatient medical and surgical therapy use, except for intensive care procedures, was similar for DNR and non-DNR inpatients. Residents with DNR orders had a higher mortality rate, yet most survived at least 1 year after the order. In the short term, a DNR order had no impact on measured health care resource consumption, but, for those in the final months of life, in-patient hospital use was less for the DNR group, and most of these died at the nursing home.

CONCLUSIONS

Prehospital code status decisions can be made effectively within the NH setting. Outside of medical intensive care, DNR orders have no impact on NH and hospital care intensity in the short term. In the final 6 months of life, however, hospital use is less for the DNR subgroup.