Article, Cardiology

In-hospital cardiac arrest: characteristics and outcome after implementation of systematic practice-oriented training

a b s t r a c t

Survival after in-hospital cardiac arrest has been reported to be surprisingly low without any major improvement during the last decade. Cardiopulmonary resuscitation (CPR) quality affects survival after CA, and specific education is necessary for health care professionals participating in CPR. Decisions regarding CPR and do not attempt resuscitation (DNAR) orders remain demanding, as does including patients in the process. Addressed training regarding CPR/DNAR orders is necessary to improve the CPR/DNAR decision process used by physicians. The aim of this retrospective study is to evaluate the clinical impact (return of spontaneous circulation and 21-day survival after CA) of an intervention within one single hospital, including a systematic education of all health care professionals in CPR. In total, there were 33 in-hospital CAs before (12 months) and 176 after (36 months) the intervention. No significant difference was found between the 2 calendar periods.

(C) 2014

Background

European Resuscitation Council (ERC) has increased its focus on Cardiac arrest and endeavor to inform health care professionals about the existing guidelines for resuscitation. These guidelines have been changed 3 times since 2000; hence, today, much of the treatment of CA is based on existing scientific evidence [1]. Now is the time to ascertain, if the use of the algorithms in hospitals are beneficial and to define and discuss possible outcomes. One would presume that the overall outcome has improved survival.

Very little research with focus on outcome after in-hospital CA has been published. When looking at major international studies, the surviving rate after CA (15%-30%) has not changed during the last decade [2-4]. Until today, there is only one systematic calculation of CA in Danish hospitals [5], this, in spite of the Danish Quality Model (DDKM), which requires hospitals to monitor the quality of their Cardiac resuscitation. The aim of this retrospective study is to evaluate the clinical impact (return of spontaneous circulation [ROSC] and 21- day survival after CA) of an intervention within one single hospital, consisting of a systematic education of all health care professionals in cardiopulmonary resuscitation (CPR).

? No source(s) of support in the form of equipment, drugs, or grants.

* Corresponding author. Belfastvej 4, 2300 Copenhagen S, Denmark.

E-mail address: [email protected] (E. Ramberg).

Methods

This exploratory project was carried out at Holbaek Hospital in Denmark from 2006 to 2010. Holbaek Hospital has an emergency department and 305 medical and surgical beds.

Represented in every CA team at Holbaek Hospital are 4 persons: one team leader (medical physician), one anesthesiologist, one anesthesiological nurse, and one orderly. Besides the CA team personnel from the ward involved is also represented. Holbaek Hospital uses the Resuscitation guidelines from ERC [1].

The DDKM demanded in 2006 that Holbaek Hospital set up a local CA committee. The aim of this committee work was to focus on the treatment of CA. The committee was prompted to start a CA education of the hospital’s personnel, based on the different groups of employees’ varying existing skills and to make sure that standardized equipment was available. In the same period, it was decided to set up a quality assessment, by making a form following the Utstein criteria [6], in which all data during a CA were to be registered.

In 2007, we intervened by establishing formalized education for physicians and nurses in the medical and anesthesiological apart- ments. The teaching composed of both basic life support (BLS) and Advanced life support . The ALS course consisted of an 8-hour theoretical and practical training, where all the participants got to practice the different rolls in a CA team. Focused debriefing was also a part of the training. In the teaching scenarios, we used ResusciAnne, and all the teachers were ALS-certified physicians with specific interest in teaching.

http://dx.doi.org/10.1016/j.ajem.2014.04.009

0735-6757/(C) 2014

766 E. Ramberg et al. / American Journal of Emergency Medicine 32 (2014) 765767

The remaining hospital personnel received BLS education of 90 minutes, as a part of the mandatory introduction program at Holbaek Hospital.

In the control group from 2006, data were collected via a manual review of all patient medical charts. We have not used data from 2007, the year in which the new organization and education were established and implemented. Data in the intervention group are from 2008 to 2010, where the number of completed CA forms was compared with the recorded cases of CA, and missing registrations in the forms were retrospectively filled in.

Ultimo 2008 hypothermia treatment with a target temperature of 33?C was established in Holbaek Hospital for all patients with successful resuscitation.

Multiple linear regressions were used when analyzing data toward our 2 end points: “ROSC” and “the proportion of patients alive at day 21.” The meaning of each variable was examined by a simple model reduction. Fisher exact test was used to analyze the 2 x 2 contingency tables. The Danish Data Protection Agency has approved data collection. According to Danish national law, approval from the regional ethics committee was not required.

Results

This intervention study included 209 patients with CA. Thirty-three of these incidents occurred in 2006 and 176 from 2008 to 2010 (Table).

We found no significant difference between the 2 periods, before/ after the intervention, regarding our 2 end points. Calculations show that, with an increased 21-day survival rate of 3%, with ? = .05 and a power equals of 0.8, a little more than 1000 patients in each group would be needed to reach statistical significance [7].

There was a significant increase in the resuscitation attempts per hospital bed: calendar period 1 had 0.11 attempts per bed, and calendar period 2 had 0.19 attempts per bed (P = .004). This resulted in an increase of 55% of patients achieving ROSC per year in the hospital in period 2 vs period 1 (P = .17) and a 113% increase in patients alive at day 21 in the hospital (32 patients in the years 2008- 2010 vs 5 patients in 2006) (P = .12).

We found significantly greater chance of achieving ROSC and long- term survival if the patient’s initial rhythm during CA was registered as a shockable rhythm (ventricular tachycardia/fibrillation) (P =

.001; odds ratio [OR] = 3.36; 95% confidence interval [CI], 1.64-6.89). Sex, time of CA, and the department in which the arrest took place did not influence on the incidence of ROSC or the number of patients who survived to day 21. In general, there was a greater likelihood of long- term survival to day 21 if the patient with CA was young of age (P =

.01; OR = 0.97; 95% CI, 0.95-0.99).

Discussion

Registration of in-hospital CA is considered to be crucial to ascertain the quality of care and thus potentially improve the rate of survival.

We found a nonsignificant 3% increase in 21-day survival, from 15% to 18% after resuscitation attempts in the intervention group vs the control group. With this minor effect in the intervention group, this study was clearly underpowered to statistically detect such difference. In a Danish report from Skejby University Hospital published in 2012, a 30-day survival rate of 32% was found [5]. Similarly, the Swedish Cardiac Arrest Registry [4] also present significantly higher survival rates compared with our results. We are not certain what caused this difference. The fact that we have approximately a 1-hour journey to a center capable of invasive cardiac procedures, probably have a marked negative influence on our outcome after CA. Furthermore, Holbaek is situated in a low-income area, where the patient group is known to have a higher morbidity before the CA.

postresuscitation care should also be kept in mind when long-term survival after CA is being investigated.

The aim of introducing systematic education in CPR for the entire hospital staff was to increase the quality of treatment. A small increase in quality was accomplished, but unexpectedly, we gained more in another area. The number of resuscitation attempts per year rose significantly leading to a dramatic increase in lives saved.

There are at least 2 possible explanations for this finding: Generally, our staff may now feel more confident with resuscita-

tion and actually start more attempts than before the intervention.

Table

Descriptive data

Calendar period 1a Calendar period 2b Difference per

n (%)

n (%)

year between

period 1 & 2

Total

33

176

Age, y

70 [24-95]

71 [2-94]

Sex, female Time of CA

Day

11 (33)

8 (24)

73(42)

59 (34)

Night Place of CA

Ortopedic surgery department

24 (73)

2 (6)

105 (60)

8 (5)

+33%

Internal medicine department

13 (40)

54 (31)

+38%

Emergency department

2 (6)

5 (3)

-16%

abdominal surgery department

5 (15)

22 (13)

+47%

cardiology department

9 (27)

53 (30)

+96%

ICU

1 (3)

21 (12)

+600%

Other (diagnostic/pediatric department) Cause of CA

Primary

1 (3)

6 (18)

13 (7)

24 (14)

+333%

+33%

Secondary

23 (70)

114 (65)

+65%

Initial ECG rythm

Shockable

6 (18)

34 (19)

+88%

Nonshockable

27 (82)

142 (81)

+75%

ROSC

14 (42)

65 (37)

+55%

Alive, day 21

5 (15)

32 (18)

+113%

a Calendar period before the intervention year, 2006.

b Calendar period after the intervention year, 2008 to 2010.

E. Ramberg et al. / American Journal of Emergency Medicine 32 (2014) 765767 767

This was most evident in the diagnostic departments and at the pediatric clinic, where CA might be quite rare and the staff consequently inexperienced in CA treatment. Here, we found a 333% increase in resuscitation attempts after implementation of our training program. Furthermore, it must be assumed that any kind of cardiac resuscitation training will increase focus and will improve general knowledge on cardiac disease and awareness of signs and symptoms on imminent CA, thereby leading to better ability to make the right decisions [8,9].

Because there was a 96% increase in CA treated in the department of cardiology and a 600% increase in CA treated in the intensive care unit (ICU), it is likely that a larger proportion of patients at risk of CA was transferred from general wards to these departments for electrocardio- graphic (ECG) surveillance, leading to more frequent and more swift response to CA events.

Patients with a shockable rhythm in the ECG have a better chance of resuscitation than patients without a shockable rhythm [2,3]. Our study support these findings. Significantly, more patients with ventricular tachycardia or fibrillation achieved ROSC and survived to day 21. Furthermore, after the intervention, we observed proportionally more patients with an Initial shockable rhythm (an 88% increase vs only a 75% increase in nonShockable rhythms). A higher number of patients on ECG surveillance, better ECG recognition, and increased focus on BLS among all hospital employees may have contributed to this development.

The hospital orderly member of our CA team brings the defibrillator to the place of CA. This organization can negatively affect the response time in a CA situation. Unfortunately, it has not been possible to change this organization in the hospital during the data recording period. When most patients in our study have a nonshock- able rhythm at the initial ECG rhythm assessment, it may be caused by the fact that BLS has been performed for a relatively long time before the defibrillator arrives but could also be due to the high represen- tation of secondary CAs in our population.

During 2008, postresuscitation hypothermia was implemented in our hospital, which at that time was widely believed to have a positive impact on the outcome. However, the recently published Targeted temperature management study has surprisingly shown that hypo- thermia is not beneficial [10]; hence, this is not the reason for the increased survival in this study.

We found a significantly greater chance of survival to day 21 in younger patients compared with older people in both intervention groups. In studies similar to ours, a better survival rate after CA has also been found for Young people, and significant differences in survival after CA has been observed, when regarding sex, time of the events emerge, and in which department the CA occurred [8,11,12].

The fact that our data sample was incomplete according to the Utestin criteria is a weakness in our study. When doing research on CA occurring in hospitals, standardization and correct/wide- ranging registration of data are of great importance and therefore highly recommended.

The persistently high mortality in CA in our hospital even after the intervention may be due to a high proportion of terminally ill patients. Because improvement in survival rates and quality of life after CA is the goal, focus should be on avoiding CPR of the terminally ill patient. The patient’s attitude toward cardiac resuscitation should be defined early in all hospitalized patients. A representative survey of 1669 Californians have shown that only 5% were against talking about end-of-life wishes with a physician, 16% were uncertain, and the remaining 79% would “definitely or probably” like to discuss that subject [13].

Many physicians find it difficult to initiate conversation about resuscitation [14]. A stressful, busy everyday practice may cause physicians to fail to recognize that the patient is dying or a long difficult conversation concerning whether to initiate resuscitation in case of CA with the patient, and the family members can seem chaotic and overly time consuming. To help overcome these difficulties, ERC has made guidelines from 2010 on how to deal with these recurring ethical aspects and end-of-life decisions [15].

Conclusion

Surprisingly, systematic education in BLS and ALS at a county hospital only slightly improved the immediate survival or 21-day survival in patients with CA.

However, a significantly larger number of CPR attempts were initiated, resulting in a marked increase in patients surviving CA at the hospital. The positive indications found in this pilot study need to be confirmed in a larger study.

It is our hope that our data will support the development and focus on this area. It would be positive and a proactive accomplishment if a national registers of CAs in hospitals was created. In this way, a sufficient CPR database could be established and provide information that could help improving the outcome after CA in hospital.

References

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