Survival after in-hospital cardiopulmonary resuscitation. A meta-analysis

In-hospital cardiac arrest: Incidence, prognostic factors and results

BACKGROUND AND AIMS

In-hospital cardiac arrest (CA) is a clinical entity with high morbidity and mortality that occurs in up to 2% of hospitalized patients. It is a public health problem with important economic, social, and medical repercussions, and as such its incidence needs to be reviewed and improved. The aim of this study was to determine the incidence of in-hospital CA, return of spontaneous circulation (ROSC), and survival rates at Hospital de la Princesa, and to define the clinical and demographic characteristics of patients with in-hospital CA.

PATIENTS AND METHODS

Retrospective observational chart review of patients presenting in-hospital CA and treated by anaesthesiologists from the hospital's rapid intervention team. Data were collected over 1 year.

RESULTS

Forty four patients were included in the study, of which 22 (50%) were women. Mean age was 75.7 years (±15.78 years), and incidence of in-hospital CA was 2.88 per 100,000 hospital admissions. Twenty two patients (50%) achieved ROSC and 11 patients (25%) survived until discharge home. The most prevalent comorbidity was arterial hypertension (63.64%); 66.7% of cases were not witnessed, and only 15.9% presented a shockable rhythm.

CONCLUSIONS

These results are similar to those reported in other larger studies. We recommend introducing immediate intervention teams and devoting time to training hospital staff in in-hospital CA.

Association between frailty and clinical outcomes in hospitalised patients requiring Code Blue activation

BACKGROUND

Code Blues allow a rapid, hospital wide response to acutely deteriorating patients. The concept of frailty is being increasingly recognised as an important element in determining outcomes of critically ill patients. We hypothesised that increasing frailty would be associated with worse outcomes following a Code Blue.

AIMS

To investigate the association between increasing frailty and outcomes of Code Blues.

METHODS

Single-centre retrospective design of patients admitted to Frankston Hospital in Australia between 1 January 2013 and 31 December 2017 who triggered a Code Blue. Frailty evaluation was made based on electronic medical records as were the details and the outcomes of the Code Blue. The primary outcome measure was a composite of hospital mortality or Cerebral Performance Categories scale ≥3. Secondary outcomes included the immediate outcome of the Code Blue and hospital mortality.

RESULTS

One hundred and forty-eight of 911 screened patients were included in the final analysis. Seventy-three were deemed 'frail' and the remainder deemed 'fit'. Seventy-eight  percent of frail patients reached the primary outcome, compared with 41% of fit patients (P < 0.001). Multivariable analysis demonstrated frailty to be associated with primary outcome (odds ratio = 2.87; 95% confidence interval (CI) 1.28-6.44; P = 0.01). A cardiac aetiology for the Code Blue was also associated with an increased odds of primary outcome (OR = 3.52; 95% CI 1.51-8.05; P = 0.004).

CONCLUSIONS

Frailty is independently associated with the composite outcome of hospital mortality or severe disability following a Code Blue. Frailty is an important tool in prognostication for these patients and might aid in discussions regarding treatment limitations.

Predicting neurological outcomes after in-hospital cardiac arrests for patients with Coronavirus Disease 2019

Background

Machine learning models are more accurate than standard tools for predicting neurological outcomes in patients resuscitated after cardiac arrest. However, their accuracy in patients with Coronavirus Disease 2019 (COVID-19) is unknown. Therefore, we compared their performance in a cohort of cardiac arrest patients with COVID-19.

Methods

We conducted a retrospective analysis of resuscitation survivors in the Get With The Guidelines®-Resuscitation (GWTG-R) COVID-19 registry between February 2020 and May 2021. The primary outcome was a favorable neurological outcome, indicated by a discharge Cerebral Performance Category score ≤ 2. Pre- and peri-arrest variables were used as predictors. We applied our published logistic regression, neural network, and gradient boosted machine models developed in patients without COVID-19 to the COVID-19 cohort. We also updated the neural network model using transfer learning. Performance was compared between models and the Cardiac Arrest Survival Post-Resuscitation In-Hospital (CASPRI) score.

Results

Among the 4,125 patients with COVID-19 included in the analysis, 484 (12 %) patients survived with favorable neurological outcomes. The gradient boosted machine, trained on non-COVID-19 patients was the best performing model for predicting neurological outcomes in COVID-19 patients, significantly better than the CASPRI score (c-statistic: 0.75 vs 0.67, P < 0.001). While calibration improved for the neural network with transfer learning, it did not surpass the gradient boosted machine in terms of discrimination.

Conclusion

Our gradient boosted machine model developed in non-COVID patients had high discrimination and adequate calibration in COVID-19 resuscitation survivors and may provide clinicians with important information for these patients.

Trends in In-Hospital Cardiopulmonary Resuscitation from 2010 through 2019: A Nationwide Cohort Study in South Korea

We aimed to examine recent trends in in-hospital cardiopulmonary resuscitation in South Korea from 2010 to 2019. A population-based sample of all adult patients who experienced in-hospital cardiopulmonary resuscitation between 1 January 2010 and 31 December 2019, was included. In all, 298,676 patients who received in-hospital cardiopulmonary resuscitation were included in the survival analysis. In 2010, 60.7 per 100,000 adults experienced in-hospital cardiopulmonary resuscitation. A similar rate was observed until 2015. The rate increased to 83.5 per 100,000 adults in 2016 and gradually increased to 92.1 per 100,000 adults in 2019. Among all patients, 78,783 (26.2%) were discharged alive after in-hospital cardiopulmonary resuscitation. The 6-month and 1-year survival rates were 9.8% and 8.7%, respectively. In 2010, the mean total cost of hospitalization was USD 5822.80 (United States Dollar) (standard deviation; SD: USD 7493.4), which increased to USD 7886.20 (SD: USD 13,071.6) in 2019. The rate of in-hospital cardiopulmonary resuscitation and cost of care have significantly increased since 2010, while the 6-month and 1-year rates of survival post in-hospital resuscitation remain low.

Advance and future care planning: strategic approaches in Wales

BACKGROUND

In Wales, the term advance care planning now falls under the wider umbrella term 'Future Care Planning', which also includes patients with diminished mental capacity and their significant others, to engage in deciding and planning future care. Over the last 5 years, work has been undertaken to create education formats, resources and national documents, and this has been informed by a national Advance and Future Care Planning steering group and national conference, which included patient and carer representatives. This helped collate relevant data.

AIM

We outline key strategic approaches in Wales with regard to future care planning.

RESULTS

With data from our national conference and through feedback from stakeholders, a national repository of distinct resources, forms and education formats has been created. The approach seeks to cater for the disparate need of the Welsh population; there is not merely one format for multiple scenarios, but a choice of approaches, communication strategies and documents to suit bespoke needs.

CONCLUSION

Advance and future care planning is an approach with many different facets. In Wales, we have found that some patients prefer a clearly set out, legally binding 'Advance Decision to Refuse Treatment' to guide their care, while others prefer a softer, guiding approach captured through an Advance Statement. All these formats are available to patients, carers and healthcare professionals, together with explanatory guidance notes, through a central Welsh website. Next steps involve getting a central electronic repository for these forms, which is accessible to healthcare providers and to patients.

Comparison of Machine Learning Methods for Predicting Outcomes After In-Hospital Cardiac Arrest

OBJECTIVES

Prognostication of neurologic status among survivors of in-hospital cardiac arrests remains a challenging task for physicians. Although models such as the Cardiac Arrest Survival Post-Resuscitation In-hospital score are useful for predicting neurologic outcomes, they were developed using traditional statistical techniques. In this study, we derive and compare the performance of several machine learning models with each other and with the Cardiac Arrest Survival Post-Resuscitation In-hospital score for predicting the likelihood of favorable neurologic outcomes among survivors of resuscitation.

DESIGN

Analysis of the Get With The Guidelines-Resuscitation registry.

SETTING

Seven-hundred fifty-five hospitals participating in Get With The Guidelines-Resuscitation from January 1, 2001, to January 28, 2017.

PATIENTS

Adult in-hospital cardiac arrest survivors.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 117,674 patients in our cohort, 28,409 (24%) had a favorable neurologic outcome, as defined as survival with a Cerebral Performance Category score of less than or equal to 2 at discharge. Using patient characteristics, pre-existing conditions, prearrest interventions, and periarrest variables, we constructed logistic regression, support vector machines, random forests, gradient boosted machines, and neural network machine learning models to predict favorable neurologic outcome. Events prior to October 20, 2009, were used for model derivation, and all subsequent events were used for validation. The gradient boosted machine predicted favorable neurologic status at discharge significantly better than the Cardiac Arrest Survival Post-Resuscitation In-hospital score (C-statistic: 0.81 vs 0.73; p < 0.001) and outperformed all other machine learning models in terms of discrimination, calibration, and accuracy measures. Variables that were consistently most important for prediction across all models were duration of arrest, initial cardiac arrest rhythm, admission Cerebral Performance Category score, and age.

CONCLUSIONS

The gradient boosted machine algorithm was the most accurate for predicting favorable neurologic outcomes in in-hospital cardiac arrest survivors. Our results highlight the utility of machine learning for predicting neurologic outcomes in resuscitated patients.

Predicting in-hospital mortality after an in-hospital cardiac arrest: A multivariate analysis

Aim of the study

Most survivors of an in-hospital cardiac arrest do not leave the hospital alive, and there is a need for a more patient-centered, holistic approach to the assessment of prognosis after an arrest. We sought to identify pre-, peri-, and post-arrest variables associated with in-hospital mortality amongst survivors of an in-hospital cardiac arrest.

Methods

This was a retrospective cohort study of patients ≥18 years of age who were resuscitated from an in-hospital arrest at our University Medical Center from January 1, 2013 to September 31, 2016. In-hospital mortality was chosen as a primary outcome and unfavorable discharge disposition (discharge disposition other than home or skilled nursing facility) as a secondary outcome.

Results

925 patients comprised the in-hospital arrest cohort with 305 patients failing to survive the arrest and a further 349 patients surviving the initial arrest but dying prior to hospital discharge, resulting in an overall survival of 29%. 620 patients with a ROSC of greater than 20 min following the in-hospital arrest were included in the final analysis. In a stepwise multivariable regression analysis, recurrent cardiac arrest, increasing age, time to ROSC, higher serum creatinine levels, and a history of cancer were predictors of in-hospital mortality. A history of hypertension was found to exert a protective effect on outcomes. In the regression model including serum lactate, increasing lactate levels were associated with lower odds of survival.

Conclusion

Amongst survivors of in-hospital cardiac arrest, recurrent cardiac arrest was the strongest predictor of poor outcomes with age, time to ROSC, pre-existing malignancy, and serum creatinine levels linked with increased odds of in-hospital mortality.

A simple ABCD score to stratify patients with respect to the probability of survival following in-hospital cardiopulmonary resuscitation

BACKGROUND

Cardiopulmonary resuscitation (CPR) is occurring more frequently at community hospitals but most patients undergoing CPR do not survive to discharge. Tools to predict CPR survival can be improved by the identification of high-yield clinical indicators.

OBJECTIVE

To identify variables associated with survival to discharge following in-hospital cardiac arrest.

METHODS

Retrospective cohort study of 463,530 hospital admissions from the Nationwide Inpatient Sample (2012-2016). The analysis includes adults (age ≥50) who underwent in-hospital CPR at US community hospitals.

RESULTS

Overall survival to discharge was 29.8% (95% CI: 29.5-30.1%). Age was the strongest predictor of survival and had greater prognostic value than the Charlson comorbidity index. Obesity was associated with improved survival (35.9%, 95% CI: 35.1-36.7%), whereas underweight patients had decreased survival (24.0%, 95% CI: 22.2-25.7%). Acute indicators of poor survival included hyperkalemia, hypercalcemia, and sepsis. We generated an ABCD index based upon four high-yield variables (age, body habitus, comorbidity, day of hospital admission). An ABCD score of 2 or less was a sensitive but non-specific predictor of post-CPR survival (96.8% sensitivity, 95% CI: 96.6-97.0), and those with extreme scores differed 3.8-fold with respect to post-CPR survival probability (46.0% versus 12.1%).

CONCLUSION

Age is the strongest predictor of post-CPR survival, but body habitus is also an important indicator that may currently be underutilized. Our results support improved post-CPR survival of obese patients, consistent with an 'obesity paradox'. The ABCD score provides an efficient means of risk-stratifying patients and can be calculated in less than 1 minute.

Extracorporeal cardiopulmonary resuscitation (ECPR) survival: A quaternary center analysis

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue strategy for nonresponders to conventional CPR (CCPR) in cardiac arrest. Definitive guidelines for ECPR deployment do not exist. Prior studies suggest that arrest rhythm and cardiac origin of arrest may be variables used to assess candidacy for ECPR.

AIM

To describe a single-center experience with ECPR and to assess associations between survival and physician-adjudicated origin of arrest and arrest rhythm.

METHODS

A retrospective review of all patients who underwent ECPR at a quaternary care center over a 7-year period was performed. Demographic and clinical characteristics were extracted from the medical record and used to adjudicate the origin of cardiac arrest, etiology, rhythm, survival, and outcomes. Univariate analysis was performed to determine the association of patient and arrest characteristics with survival.

RESULTS

Between 2010 and 2017, 47 cardiac arrest patients were initiated on extracorporeal membrane oxygenation (ECMO) at the time of active CPR. ECPR patient survival to hospital discharge was 25.5% (n = 12). Twenty-six patients died on ECMO (55.3%) while nine patients (19.1%) survived decannulation but died before discharge. Neither physician-adjudicated arrest rhythm nor underlying origin were significantly associated with survival to discharge, either alone or in combination. Younger age was significantly associated with survival. Nearly all survivors experienced myocardial recovery and left the hospital with a good neurological status.

CONCLUSIONS

Arrest rhythm and etiology may be insufficient predictors of survival in ECPR utilization. Further multiinstitutional studies are needed to determine evidenced-based criteria for ECPR deployment.

An Ethically Justified Approach That Integrates Advance Directives Discussions With Care of the Patient With Cancer

Although the frequency of advance directives discussions may be increasing, there is a need to improve the quality of these discussions. In a range of advanced medical illnesses, including cancer, poor outcomes with advanced cardiopulmonary life support (ACLS) have been well documented. However, when speaking to patients at the end-of-life, physicians frequently withhold evidence-based information and guidance about prognosis or outcomes of ACLS. Tools and models developed to facilitate communication at the end-of-life do not explicitly include recommendations on advance directives and specifically do not discuss the available evidence on ACLS outcomes in the seriously ill. Here, we review the current literature on outcomes of ACLS and current tools and communications for end-of-life discussions. A majority of patients have a preference for truth-telling and guidance. We advocate an approach that integrates individual goals and preferences with a shared understanding of prognosis and appropriate management options, as judged and recommended by the disease experts, in order to reach an evidence-based decision on advance directives. This pragmatic and ethically justified approach emphasizes active empathic communication to prioritize the care of the patient over the mechanical details of ACLS, thereby aligning end-of-life discussions with current practices in other domains of medicine.

Mass Gathering Medicine (Hajj Pilgrimage in Saudi Arabia): The Outcome of Cardiopulmonary Resuscitation during Hajj

The annual Hajj (pilgrimage) to the Islamic holy shrines at the city of Makkah in the Kingdom of Saudi Arabia is one of the largest yearly recurring mass gatherings worldwide. We aim to evaluate the outcome of outside and inside the hospital cardiopulmonary resuscitation to resuscitate cardiopulmonary arrest among pilgrims. In a prospective cohort study of cardiac arrest patients during Hajj period (January 2004–December 2007 and January 2010–December 2011), 426 patients were resuscitated. The mean age was 64.0 ± 12.0 years. A total of 252 (52.2%) patients had an outside the hospital cardiac arrest, whereas 174 (40.8%) patients had an inside the hospital cardiac arrest. The survival rate of outside the hospital was 5%, whereas inside the hospital was 30%. The overall survival rate was 15.5%. During Hajj, cardiopulmonary resuscitation inside the hospital was associated with better clinical outcomes than outside the hospital. Patients with cardiac arrest outside of the hospital are much less likely to survive due to the lack of immediately trained help and the delay of arrival of aid due to overcrowding. Sudden cardiac arrest leading to death could be minimized if cardiopulmonary resuscitation and defibrillation are delivered before the arrival of emergency medical services.

Predicting the probability of survival with mild or moderate neurological dysfunction after in-hospital cardiopulmonary arrest: The GO-FAR 2 score

BACKGROUND

The Good Outcome Following Attempted Resuscitation (GO-FAR) Score uses pre-arrest factors to predict survival after In-Hospital Cardiac Arrest (IHCA) with minimal neurological dysfunction, (cerebral performance category (CPC) ≤1). Moderate neurological dysfunction (CPC ≤2) may be a more acceptable outcome.

OBJECTIVE

To predict survival after IHCA with mild or moderate neurological dysfunction based on pre-arrest factors.

METHODS

52,468 patients with IHCA from 2012-2017. Data was divided into training (44%), testing (22%), and validation (34%) sets. Univariate analysis was used to identify variables with >3% difference in survival with CPC ≤2. These variables carried forward to the multivariate logistic regression model. The most parsimonious model that best classified patients as having a very poor (≤5%), below average (≤10%), average (11%-30%), or above average (>30%) likelihood of survival with CPC ≤2 was chosen.

RESULTS

Age >85, admission CPC <2, and non-surgical admission were strongly association with poor survival (-12.1%, -14.4%, and -18%, respectively). Nine variables were included in the logistic regression analysis. The final updated model, GO FAR 2, categorized 6.2% of patients with a very poor predicted survival, 24.8% of patients with a below average predicted survival, and 11.3% with above average predicted survival. The observed survival among those with very poor predicted survival was 4.5%.

CONCLUSION

The GO FAR 2 score provides clinicians with a prognostic estimate of the likelihood of a good outcome after IHCA based on pre-arrest patient factors. Future research is required to validate the GO-FAR 2 score.

Supporting shared decision-making about cardiopulmonary resuscitation using a video-based decision-support intervention in a hospital setting: a multisite before-after pilot study

BACKGROUND

Inpatients are often prescribed cardiopulmonary resuscitation (CPR) without a shared decision-making process. Since implementation of decision aids into practice is highly sensitive to the clinical milieu, we performed a pilot study to refine our study procedures and to evaluate the acceptability and potential effectiveness of a shared decision-making intervention when implemented in a Canadian hospital setting.

METHODS

In this before-after pilot study, we recruited patients and family members on the medical wards of 2 Canadian teaching hospitals between September 2015 and March 2017. The intervention consisted of viewing a CPR decision video and completing a values-clarification worksheet; follow-up discussion with the physician was encouraged. The primary feasibility outcome was acceptability of the video, and the primary effectiveness outcome was change in the Decisional Conflict Scale score (lower scores being more desirable) after the intervention. Participants rated the extent of shared decision-making using the CollaboRATE instrument.

RESULTS

Of the 71 participants (43 patients with a mean age of 79.0 [standard deviation (SD) 11.4] yr and 28 family members with a mean age of 61.0 [SD 10.0] yr), 65 (92%) rated the CPR decision video as good to excellent. The intervention was associated with an improvement in knowledge about CPR (+2.7 points, 95% confidence interval [CI] 2.2 to 3.3, effect size 1.5) and a reduction in the Decisional Conflict Scale score (-18.1 points, 95% CI -21.8 to -14.3, effect size 1.4). The 36 participants who had a discussion with a physician about CPR after watching the video rated the extent of shared decision-making as 6.3 (SD 1.7) (possible maximum score 9). There was a nonsignificant decrease in the proportion of patients with a medical order for CPR after the intervention (71% before v. 63% after, p = 0.06).

INTERPRETATION

The CPR decision video was acceptable to patients and family members. Our decision-support intervention may improve knowledge, reduce decisional conflict and reduce the prevalence of medical orders for CPR in the Canadian hospital setting.

Perioperative Advance Directives: Do Not Resuscitate in the Operating Room

Surgeons, anesthesiologists, and nurses are frequently asked to operate on patients with an existing Do Not Resuscitate (DNR) order, resulting in confusion about the proper approach. We discuss the origins of decisions not to attempt resuscitation, the special circumstances surrounding the need for resuscitation intraoperatively, and reasons to suspend, or not suspend, the DNR order during the perioperative period. DNR should be part of a comprehensive discussion of a patient and family's goals of care. A clear understanding of those goals will lead the care team to a better understand the role of perioperative resuscitation for that individual patient.

Comparing in-patient extracorporeal cardiopulmonary resuscitation to standard cardiac treatment group of extracorporeal membrane oxygenation patients: 8 years of experience at a single institution

INTRODUCTION

Post-cardiac arrest survivals remain low despite the effort of cardiopulmonary resuscitation. Utilization of extracorporeal membrane oxygenation during cardiopulmonary resuscitation (extracorporeal cardiopulmonary resuscitation) can provide immediate cardiovascular support and potentially improve outcomes of patients with cardiac arrest requiring cardiopulmonary resuscitation. There is renewed interest in the use of extracorporeal cardiopulmonary resuscitation due to improved outcomes over the years.

METHODS

Extracorporeal membrane oxygenation data between 2010 and 2018 were reviewed. Patients with extracorporeal membrane oxygenation placed under cardiopulmonary resuscitation were identified, and demographics, extracorporeal membrane oxygenation survival, survival to discharge, and neurological recovery were retrospectively analyzed with institutional review board approval.

RESULTS

Among 230 cases of extracorporeal membrane oxygenation, 34 (21 males and 13 females, age of 49 ± 13 years) underwent extracorporeal cardiopulmonary resuscitation. The mean duration of extracorporeal membrane oxygenation support after extracorporeal cardiopulmonary resuscitation was 8.3 ± 7.9 days. Extracorporeal membrane oxygenation mortality among extracorporeal cardiopulmonary resuscitation patients was 32% (11/34) and hospital survival was 38% (13/34), which are similar to standard cardiac extracorporeal membrane oxygenation (extracorporeal membrane oxygenation survival 62% and hospital survival 39% in cardiac extracorporeal membrane oxygenation). Among the extracorporeal membrane oxygenation death after extracorporeal cardiopulmonary resuscitation, the majority was due to neurological injury (73%, 8/11); 8/34 extracorporeal membrane oxygenation survival rate and 30-day survival rate were 63% and 25% in early half of study (2010-2014) and have improved to 70% and 60% in late half of study (2014-2018).

CONCLUSION

Over years of experience with extracorporeal membrane oxygenation, the outcome of the extracorporeal cardiopulmonary resuscitation has been improving and appears to exceed those of traditional methods, despite limited sample size. Neurological complications still need to be addressed in order for survival and outcomes to improve.

To Code or Not To Code: Teaching Multidisciplinary Clinicians to Conduct Code Status Discussions

Background: Code status discussions (CSDs) can be challenging for many clinicians. Barriers associated with them include lack of education, comfort level, and experience. Objective: To conduct an educational intervention to improve knowledge and communication approaches related to CSDs. Design: A cross-sectional multidisciplinary educational intervention was conducted over one year consisting of an interactive presentation, live role-play, and pre- and post-intervention tests to measure impact of the formal training. Evaluations and comments were also collected. Setting/Subjects: Attending physicians, nurses, residents, fellows, and physician assistants (PAs) at an urban community teaching hospital of 500 beds serving an ethnically diverse population. Measurements: Data from pre- and post-intervention tests evaluating knowledge and communication approach regarding CSDs were collected. Participants completed a qualitative evaluation of the program. Results: There were 165 participants: 29 attending physicians, 26 residents, 17 fellows, 18 PAs, and 75 nurses. All (100%) completed the pre-intervention test and 154 (93.3%) completed the post-intervention test. There was an overall improvement in scores, 43.8% pre-intervention to 75.6% post-intervention (p-values <0.005). Attending physicians and fellows had the highest pre-intervention scores, while nurses and PAs had the lowest. Most participants (97%) reported they learned new information and 91% stated they would change patient management. Conclusions: Our study found that a brief educational intervention with multipronged teaching tools improved knowledge concerning CSDs. Participants felt it provided new insights and would change their practice. This study contributes to the literature by examining CSD training across different disciplines, allowing for cross-group comparisons. Future studies should try to correlate educational interventions and clinician knowledge with clinical practice outcomes.

End-of-Life Care for Seriously Ill International Patients at a Global Destination Medical Center

OBJECTIVE

To characterize the end-of-life care of all international patients who died at a global destination medical center from January 1, 2005, through December 31, 2015.

PATIENTS AND METHODS

We performed a retrospective review of all adult international patients who died at a global destination medical center from January 1, 2005, through December 31, 2015.

RESULTS

Eighty-two international patients from 25 countries and 5 continents died during the study period (median age, 59.5 years; 59% male). Of the study cohort, 11% (n=9) completed an advance directive, 61% (n=50) died in the intensive care unit, 26% (n=21) had a full code order at the time of death, and 73% (n=19 of 26) receiving cardiopulmonary resuscitation did not survive the resuscitation process.

CONCLUSION

Seriously ill international patients who travel to receive health care in the United States face many barriers to receiving high-quality end-of-life care. Seriously ill international patients are coming to the United States in increasing numbers, and little is known about their end-of-life care. There are many unique needs in the care of this complex patient population, and further research is needed to understand how to provide high-quality end-of-life care to these patients.

Outcomes following cardiopulmonary resuscitation in an emergency department of a low- and middle-income country

BACKGROUND

Cardiopulmonary resuscitation (CPR) is a key component of emergency care following cardiac arrest. A better understanding of factors that influence CPR outcomes and their prognostic implications would help guide care. A retrospective analysis of 800 adult patients that sustained an in- or out-of-hospital cardiac arrest and underwent CPR in the emergency department of a tertiary care facility in Karachi, Pakistan, between 2008 and 15 was conducted.

METHODS

Patient demographics, clinical history, and CPR characteristics data were collected. Logistic regression model was applied to assess predictors of return of spontaneous circulation and survival to discharge. Analysis was conducted using SPSS v.21.0.

RESULTS

Four hundred sixty-eight patients met the study's inclusion criteria, and overall return of spontaneous circulation and survival to discharge were achieved in 128 (27.4%) and 35 (7.5%) patients respectively. Mean age of patients sustaining return of spontaneous circulation was 52 years and that of survival to discharge was 49 years. The independent predictors of return of spontaneous circulation included age ≤ 49 years, witnessed arrest, ≤ 30 min interval between collapse-to-start, and 1-4 shocks given during CPR (aOR (95% CI) 2.2 (1.3-3.6), 1.9 (1.0-3.7), 14.6 (4.9-43.4), and 3.0 (1.4-6.4) respectively), whereas, age ≤ 52 years, bystander resuscitation, and initial rhythm documented (pulseless electrical activity and ventricular fibrillation) were independent predictors of survival to discharge (aOR (95% CI) 2.5 (0.9-6.5), 1.4 (0.5-3.8), 5.3 (1.5-18.4), and 3.1 (1.0-10.2) respectively).

CONCLUSION

Our study notes that while the majority of arrests occur out of the hospital, only a small proportion of those arrests receive on-site CPR, which is a key contributor to unfavorable outcomes in this group. It is recommended that effective pre-hospital emergency care systems be established in developing countries which could potentially improve post-arrest outcomes. Younger patients, CPR initiation soon after arrest, presenting rhythm of pulseless ventricular tachycardia and ventricular fibrillation, and those requiring up to four shocks to revive are more likely to achieve favorable outcomes.

Survival after in-hospital cardiac arrest among cerebrovascular disease patients

Stroke is a leading cause of death and disability, and while preferences for cardiopulmonary resuscitation (CPR) are frequently discussed, there is limited evidence detailing outcomes after CPR among acute cerebrovascular neurology (inclusive of stroke, subarachnoid hemorrhage (SAH)) patients. Systematic review and meta-analysis of PubMed and Cochrane libraries from January 1990 to December 2016 was conducted among stroke patients undergoing in-hospital CPR. Primary data from studies meeting inclusion criteria at two levels were extracted: 1) studies reporting survival to hospital discharge after CPR with cerebrovascular primary admitting diagnosis, and 2) studies reporting survival to hospital discharge after CPR with cerebrovascular comorbidity. Meta-analysis generated weighted, pooled survival estimates for each population. Of 818 articles screened, there were 176 articles (22%) that underwent full review. Three articles met primary inclusion criteria, with an estimated 8% (95% Confidence Interval (CI) 0.01, 0.14) rate of survival to hospital discharge from a pooled sample of 561 cerebrovascular patients after in-hospital CPR. Twenty articles met secondary inclusion criteria, listing a cerebrovascular comorbidity, with an estimated rate of survival to hospital discharge of 16% (95% CI 0.14, 0.19). All studies demonstrated wide variability in adherence to Utstein guidelines, and neurological outcomes were detailed in only 6 (26%) studies. Among the few studies reporting survival to hospital discharge after CPR among acute cerebrovascular patients, survival is lower than general inpatient populations. These findings synthesize the limited empirical basis for discussions about resuscitation among stroke patients, and highlight the need for more disease stratified reporting of outcomes after inpatient CPR.

Palliative care in dementia: issues and evidence

Palliative care is an approach that stands well with the aims of person-centred dementia care. There is no doubt that the standards of care for many people with advanced dementia are poor. There is a lack of good-quality evidence, however, to support any particular approach for palliative care in dementia. Still, there are a number of areas in relation to caring for people with severe dementia where a palliative approach might be beneficial. In general, the relevant decisions have to be made on an individual basis but within a palliative framework. Advance care planning is likely to be crucial in encouraging this process. There is certainly a moral imperative behind the idea that care at the end of life for people with dementia should be improved.

Analysis of functioning and efficiency of a code blue system in a tertiary care hospital

Background:

“Code blue” (CB) is a popular hospital emergency code, which is used by hospitals to alert their emergency response team of any cardiorespiratory arrest. The factors affecting the outcomes of emergencies are related to both the patient and the nature of the event. The primary objective was to analyze the survival rate and factors associated with survival and also practical problems related to functioning of a CB system (CBS).

Materials and Methods:

After the approval of hospital ethics committee, an analysis and audit was conducted of all patients on whom a CB had been called in our tertiary care hospital over 24 months. Data collected were demographic data, diagnosis, time of cardiac arrest and activation of CBS, time taken by CBS to reach the patient, presenting rhythm on arrival of CB team, details of cardiopulmonary resuscitation (CPR) such as duration and drugs given, and finally, events and outcomes. Chi-square test and logistic regression analysis were used to analyze the data.

Results:

A total of 720 CB calls were initiated during the period. After excluding 24 patients, 694 calls were studied and analyzed. Six hundred and twenty were true calls and 74 were falls calls. Of the 620, 422 were cardiac arrests and 198 were medical emergencies. Overall survival was 26%. Survival in patients with cardiac arrests was 11.13%. Factors such as age, presenting rhythm, and duration of CPR were found to have a significant effect on survival. Problems encountered were personnel and equipment related.

Conclusion:

A CBS is effective in improving the resuscitation efforts and survival rates after inhospital cardiac arrests. Age, presenting rhythm at the time of arrest, and duration of CPR have significant effect on survival of the patient after a cardiac arrest. Technical and staff-related problems need to be considered and improved upon.

Caring for critically ill oldest old patients: a clinical review

Despite technological advances, the mortality rate for critically ill oldest old patients remains high. The intensive caring should be able to combine technology and a deep humanity considering that the patients are living the last part of their lives. In addition to the traditional goals of ICU of reducing morbidity and mortality, of maintaining organ functions and restoring health, caring for seriously oldest old patients should take into account their end-of-life preferences, the advance or proxy directives if available, the prognosis, the communication, their life expectancy and the impact of multimorbidity. The aim of this review was to focus on all these aspects with an emphasis on some intensive procedures such as mechanical ventilation, noninvasive mechanical ventilation, cardiopulmonary resuscitation, renal replacement therapy, hemodynamic support, evaluation of delirium and malnutrition in this heterogeneous frail ICU population.

Doctors' attitudes towards the introduction and clinical operation of do not resuscitate orders (DNRs) in Ireland

BACKGROUND

Do not resuscitate orders (DNRs) are documents which state that should a patient suffer from cardiopulmonary failure, resuscitation should not be attempted. Internationally, DNRs are often misunderstood and used inappropriately in a clinical setting.

AIMS

The aim of this paper was to determine the current understanding of DNRs and their clinical operation among hospital doctors in Ireland.

METHODS

A cross-sectional, questionnaire-based study was conducted involving doctors from the Cork teaching hospitals. The questionnaire sought information regarding understanding of DNRs and their clinical operation, as well as attitudes regarding the current absence of relevant Irish guidelines. The questionnaire also collected information regarding demographics, clinical specialty, and level of experience.

RESULTS

45.9% (47/103) of all doctors stated that their clinical knowledge was sufficient to draft a DNR, but 48.7% of this group (n = 23) chose the incorrect definition for a DNR when provided with three separate options. Thirty-five percent (n = 36) of all doctors surveyed demonstrated an incorrect understanding of a DNR. Neither specialty nor experience level had any effect on level of understanding of DNRs (p > 0.05). 93.2% (n = 96) agreed that there is a need for introduction of domestic guidelines regarding DNRs. 57.6% (n = 59) would draft more DNRs in the event that such domestic guidelines were in place.

CONCLUSIONS

A substantial proportion of hospital doctors surveyed demonstrated an incomplete understanding of DNRs and their clinical operation. However, the overwhelming majority of the present sample believe that domestic guidelines are needed on the matter.

Cardiopulmonary resuscitation-from the patient's perspective

With increasing emphasis on patient autonomy, patients are encouraged to be more involved in end-of-life issues, including the use of extraordinary efforts to prolong their lives. Being able to make anticipatory decisions is seen to promote autonomy, empower patients and optimise patient care. To facilitate shared decision-making, patients need to have a clear and accurate understanding of cardiopulmonary resuscitation (CPR). This study aims to understand the knowledge and perspectives of the local community regarding resuscitation options and end-of-life decision-making and to explore ways to improve the quality of end-of-life discussions. An interviewer-administered survey was conducted with a prospectively recruited group of surgical patients admitted postoperatively to the day surgery ward of a single tertiary institution in Singapore from April to May 2015. The survey, modelled after two validated questionnaires, measured patients' knowledge, attitudes and preferences regarding CPR in a series of 18 questions. Fifty-one out of 67 (76.1%) patients completed the survey. Results indicated that 80.4% (n=41) of participants correctly understood the purpose of CPR, but 64.7% (n=33) did not know of any possible complications of CPR. Less than half (n=21, 41.2%) of participants had thought about life support measures they wanted for themselves. Most of the participants agreed that they should personally be involved in making end-of-life decisions (n=44, 86.3%). Many patients had a poor knowledge of CPR and other resuscitation measures and the majority overestimated the success rate of CPR. However, a majority were receptive to improving their knowledge and keen to discuss end-of-life issues with physicians.

Informed consent and the aftermath of cardiopulmonary resuscitation: Ethical considerations

BACKGROUND:

Patients often are confronted with the choice to allow cardiopulmonary resuscitation (CPR) should cardiac arrest occur. Typically, informed consent for CPR does not also include detailed discussion about survival rates, possible consequences of survival, and/or potential impacts on functionality post-CPR.

OBJECTIVE:

A lack of communication about these issues between providers and patients/families complicates CPR decision-making and highlights the ethical imperative of practice changes that educate patients and families in those deeper and more detailed ways.

DESIGN:

This review integrates disparate literature on the aftermath of CPR and the ethics implications of CPR decision-making as it relates to and is affected by informed consent and subsequent choices for code status by seriously ill patients and their surrogates/proxies within the hospital setting. Margaret Urban Walker's moral philosophy provides a framework to view informed consent as a practice of responsibility.

ETHICAL CONSIDERATIONS:

Given nurses' communicative skills, ethos of care and advocacy, and expertise in therapeutic relationships, communication around DNAR decision-making might look quite different if institutional norms in education, healthcare, law, and public policy held nurses overtly responsible for informed consent in some greater measure.

FINDINGS:

Analysis from this perspective shows where changes in informed consent practices are needed and where leverage might be exerted to create change in the direction of deeper and more detailed discussions about CPR survival rates and possible consequences of survival.

An Interventional Quality Improvement Study to Assess the Compliance to Cardiopulmonary Resuscitation Documentation in an Indian Teaching Hospital

Background

Cardiopulmonary resuscitation (CPR) should be performed as per the international guidelines; however, compliance to these guidelines is difficult to assess. This study was conducted to determine the compliance to American Heart Association (2010) guideline on CPR documentation by among resident physicians before and after resident training (two arms).

Methods

This pre-postinterventional quality improvement study was conducted in a referral center, North India. Data of hospitalized in-hospital CPR patients were collected in the form of quality indicators (checklists) as defined by the guideline and compared between two arms of before-after resident training. Residents were given appropriate training in CPR technique as per the guideline. The compliance of CPR documentation was assessed pre- and post-intervention.

Results

The baseline arm compliance of various components of CPR documentation was low. The postintervention arm compliances of all components significantly increased (baseline, 2.5% to postintervention, 15.11%, P = 0.03). Individual components assessed were documentation of assessment of responsiveness (65% to 77.9%, P = 0.19), assessment of breathing (37.5% to 58.1%, P = 0.03), assessment of carotid pulse (62.5% to 79%, P = 0.05), rate of chest compressions (20% to 39.5%, P = 0.04), airway management (62.5% to 82.5%, P = 0.02), and compressions to breaths ratio (12.5% to 31.4%, P = 0.02). Documentation of chest compression rate compared to nondocumentation (12 of 42 vs. 11 of 84, P = 0.04) was independently associated with a higher rate of return of spontaneous circulation. The study however did not show any survival benefits.

Conclusions

This study establishes that the compliance to CPR documentation is poor as assessed by CPR documentation content and quality, which improves after physician training, but not up to the mark level (100%) that may be due to busy Indian hospital settings and human behavioral factors. Due to ethical constraints of live CPR assessment, this document checklist approach may be considered as an internal quality assessment method for CPR compliance. Furthermore, correct instruction in CPR technique along with proper documentation of the procedure is required, followed up with periodic re-education during the residency period and beyond.

Outcomes of In-Hospital Cardiopulmonary Resuscitation in Patients with CKD

BACKGROUND AND OBJECTIVES

Advance care planning, including code/resuscitation status discussion, is an essential part of the medical care of patients with CKD. There is little information on the outcomes of cardiopulmonary resuscitation in these patients. We aimed to measure cardiopulmonary resuscitation outcomes in these patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Our study is observational in nature. We compared the following cardiopulmonary resuscitation-related outcomes in patients with CKD with those in the general population by using the Nationwide Inpatient Sample (2005-2011): (1) survival to hospital discharge, (2) discharge destination, and (3) length of hospital stay. All of the patients were 18 years old or older.

RESULTS

During the study period, 71,961 patients with CKD underwent in-hospital cardiopulmonary resuscitation compared with 323,620 patients from the general population. Unadjusted in-hospital mortality rates were higher in patients with CKD (75% versus 72%; P<0.001) on univariate analysis. After adjusting for age, sex, and potential confounders, patients with CKD had higher odds of mortality (odds ratio, 1.24; 95% confidence interval, 1.11 to 1.34; P≤0.001) and length of stay (odds ratio, 1.11; 95% confidence interval, 1.07 to 1.15; P=0.001). Hospitalization charges were also greater in patients with CKD. There was no overall difference in postcardiopulmonary resuscitation nursing home placement between the two groups. In a separate subanalysis of patients ≥75 years old with CKD, higher odds of in-hospital mortality were also seen in the patients with CKD (odds ratio, 1.10; 95% confidence interval, 1.02 to 1.17; P=0.01).

CONCLUSIONS

In conclusion, we observed slightly higher in-hospital mortality in patients with CKD undergoing in-hospital cardiopulmonary resuscitation.

Associations with resuscitation choice: Do not resuscitate, full code or undecided

OBJECTIVE

To examine associations of individual exposure and knowledge of resuscitation mechanics and prognosis with specific decision: Do Not Resuscitate (DNR), Full Code (FC) or Undecided (UD).

METHODS

Cross-sectional questionnaire at 3 sites: geriatric assessment center, internal medicine resident clinic, and inpatient palliative care service.

RESULTS

407 completed the questionnaire: 27% identified as DNR, 24% as FC and 49% as UD. Few (11.8%) respondents reported discussion of DNR status with their primary care doctor. DNR choice was associated with knowledge of DNR mechanics, OR=2.30 (95%CI: 1.23-4.30), physician discussion, OR=5.58 (95%CI: 2.39-13.04) and confidence in understanding own health problems, OR=2.89 (95%CI: 1.04-8.04). FC choice was associated with knowledge of FC mechanics, OR=2.01 (95%CI: 1.03-3.93) and media code exposure, OR=3.80 (95%CI: 1.46-9.92). Knowledge of resuscitation prognosis was negatively associated with FC, OR =0.48 (95%CI: 0.23-0.98).

CONCLUSION

Many individuals lack knowledge or understanding of resuscitation procedure, its risks, and prognosis. Educational efforts, for both patients and healthcare professionals, are needed to improve individual knowledge needed for informed decision.

PRACTICE IMPLICATIONS

Scheduled time for physician-patient discussion remains important for education about individual health conditions and risk/benefits related to resuscitation.

Long-term survival following in-hospital cardiac arrest: A matched cohort study

BACKGROUND

Each year, 200,000 patients undergo an in-hospital cardiac arrest (IHCA), with approximately 15-20% surviving to discharge. Little is known, however, about the long-term prognosis of these patients after discharge. Previous efforts to describe out-of-hospital survival of IHCA patients have been limited by small sample sizes and narrow patient populations

METHODS

A single institution matched cohort study was undertaken to describe mortality following IHCA. Patients surviving to discharge following an IHCA between 2008 and 2010 were matched on age, sex, race and hospital admission criteria with non-IHCA hospital controls and follow-up between 9 and 45 months. Kaplan-Meier curves and Cox PH models assessed differences in survival.

RESULTS

Of the 1262 IHCAs, 20% survived to hospital discharge. Of those discharged, survival at 1 year post-discharge was 59% for IHCA patients and 82% for controls (p<0.0001). Hazard ratios (IHCA vs. controls) for mortality were greatest within the 90 days following discharge (HR=2.90, p<0.0001) and decreased linearly thereafter, with those surviving to one year post-discharge having an HR for mortality below 1.0. Survival after discharge varied amongst IHCA survivors. When grouped by discharge destination, out of hospital survival varied; in fact, IHCA patients discharged home without services demonstrated no survival difference compared to their non-IHCA controls (HR 1.10, p=0.72). IHCA patients discharged to long-term hospital care or hospice, however, had a significantly higher mortality compared to matched controls (HR 3.91 and 20.3, respectively; p<0.0001).

CONCLUSION

Among IHCA patients who survive to hospital discharge, the highest risk of death is within the first 90 days after discharge. Additionally, IHCA survivors overall have increased long-term mortality vs.

CONTROLS

Survival rates were varied widely with different discharge destinations, and those discharged to home, skilled nursing facilities or to rehabilitation services had survival rates no different than controls. Thus, increased mortality was primarily driven by patients discharged to long-term care or hospice.

Outcomes of In-Hospital Cardiopulmonary Resuscitation in Maintenance Dialysis Patients

Outcomes of cardiopulmonary resuscitation (CPR) in hospitalized patients with ESRD requiring maintenance dialysis are unknown. Outcomes of in-hospital CPR in these patients were compared with outcomes in the general population using data from the Nationwide Inpatient Sample (NIS; 2005-2011). The study population included all adults (≥ 18 years old) from the general population and those with a history of ESRD. Baseline characteristics, in-hospital complications, and discharge outcomes were compared between the two groups. The effects of in-hospital CPR on mortality, length of stay, hospitalization charges, and discharge destination were analyzed. Yearly national trends in survival, discharge to home, and length of stay were also examined using the Cochran-Armitage trend test. During the study period, 56,069 patients with ESRD underwent in-hospital CPR compared with 323,620 patients from the general population. Unadjusted in-hospital mortality rates were higher in patients with ESRD (73.9% versus 71.8%, P<0.001) on univariate analysis. After adjusting for age, gender, and potential confounders, patients with ESRD had higher odds of mortality (odds ratio, 1.24; 95% confidence interval, 1.11 to 1.3; P<0.001). Survival after CPR improved in the year 2011 compared with 2005 (31% versus 21%, P<0.001). Multivariate analysis also revealed that a greater proportion of patients with ESRD who survived were discharged to skilled nursing facilities. In conclusion, outcomes after in-hospital CPR are improving in patients with ESRD but remain worse than outcomes in the general population. Patients with ESRD who survive are more likely to be discharged to nursing homes.

Age as a factor in do not attempt cardiopulmonary resuscitation decisions: a multicentre blinded simulation-based study

BACKGROUND

The European Resuscitation Council Guidelines recognise that there is a lack of direct evidence for the effect of age on outcome following cardiopulmonary resuscitation.

AIM

To determine the role that advancing age plays in the decision by clinicians to complete a do not attempt cardiopulmonary resuscitation order based on perceived futility.

DESIGN

A questionnaire-based trial. Clinicians were randomly assigned to receive one of two versions of a patient case, varying in age but otherwise identical (90 years vs 60 years). Participants were asked to decide whether a do not attempt cardiopulmonary resuscitation form should be completed based on perceived futility for a single patient case. Rates of do not attempt cardiopulmonary resuscitation order were compared between groups.

PARTICIPANTS

Consultant physicians, surgeons and anaesthetists from 12 district general hospitals in England.

RESULTS

In total, 291 questionnaires were returned. Overall, clinicians were significantly more likely to complete a do not attempt cardiopulmonary resuscitation form for a 90-year-old patient than a 60-year-old patient, when all other factors are equal (67.7% vs 7.4%, p < 0.001). This finding was consistent across speciality and experience level of the consultant. Surgeons were found to be significantly less likely to complete a do not attempt cardiopulmonary resuscitation order in the 90-year-old patient compared to other consultants (46.4% vs 74.1%, p < 0.001). Anaesthetists were more likely than other consultants to complete a do not attempt cardiopulmonary resuscitation order in the 60-year-old patient (17.8% vs 4.3%, p < 0.05).

CONCLUSION

Age is a highly significant independent factor in a clinicians' decision to withhold cardiopulmonary resuscitation. We highlight a potential gap between current practice and supporting evidence base.

End-of-life issues in advanced dementia: Part 1: goals of care, decision-making process, and family education

OBJECTIVE

To review the issues with setting goals of care for patients with advanced dementia, describe the respective roles of the physician and the patient's family in the decision-making process, and suggest ways to support families who need more information about the care options.

SOURCES OF INFORMATION

Ovid MEDLINE was searched for relevant articles that were published before March 7, 2014. There were no level I studies identified; most articles provided level III evidence.

MAIN MESSAGE

For patients with advanced dementia, their families have an important role in medical decision making. Families should receive timely information about the course of dementia and the care options. They need to understand that a palliative approach to care might be appropriate and does not mean abandonment of the patient. They might also want clarification about their role in the decision-making process, especially if withholding or withdrawing life-prolonging measures are considered.

CONCLUSION

Physicians should consider advanced dementia as a terminal disease for which there is a continuum of care that goes from palliative care with life-extending measures to symptomatic interventions only. Clarification of goals of care and family education are of paramount importance to avoid unwanted and burdensome interventions.

Cardiopulmonary resuscitation in the hospitalized patient: impact of system-based variables on outcomes in cardiac arrest

BACKGROUND

A better understanding of the factors affecting the outcome of inpatient cardiopulmonary resuscitation (CPR) is crucial in making key clinical decisions. We aim to study the impact of various patient-related and hospital-related variables in a community-based teaching setup that could affect the prognosis of in-hospital cardiac arrests.

METHODS

We analyzed the data on all patients who experienced cardiac arrest while hospitalized at a community teaching hospital in Youngstown, Ohio. A multivariable logistic regression was performed to identify patient- and system-based variables associated with mortality in inpatient cardiac arrest.

RESULTS

A total of 417 in-hospital cardiopulmonary arrests were recorded during the study period. We analyzed 299 events in our final sample. One hundred sixty-four patients (54.8%) achieved return of spontaneous circulation and 137 (48.5%) survived the cardiopulmonary arrest for at least 24 hours. The duration of CPR, age, initial rhythm, witnessed events and sex were strongly associated with mortality in our univariate analysis. After adjustment for age, location and whether the code was witnessed, the timing of the week, initial rhythm, the duration of CPR and the sex of the patient retained prognostic significance in predicting the mortality.

CONCLUSIONS

In our study, we report a 17.4% survival to hospital discharge after an in-hospital cardiopulmonary arrest and subsequent CPR, similar to rates reported in larger multicenter studies. Prolonged duration of CPR (>10 minutes) and male sex were found to be associated with worse outcomes. We report the impact of system-based variables such as physician and nursing staffing during different days of the week, on survival in these patients.

Cardiopulmonary Resuscitation in Patients With Terminal Illness: An Evidence-Based Analysis

BACKGROUND

Cardiopulmonary resuscitation (CPR) was first introduced in 1960 for people who unexpectedly experience sudden cardiac arrest. Over the years, it became routine practice in all institutions to perform CPR for all patients even though, for some patients with fatal conditions, application of CPR only prolongs the dying process through temporarily restoring cardiac function.

OBJECTIVES

This analysis aims to systematically review the literature to provide an accurate estimate of survival following CPR in patients with terminal health conditions.

DATA SOURCES

A literature search was performed for studies published from January 1, 2004, until January 10, 2014. The search was updated monthly to March 1, 2014.

REVIEW METHODS

Abstracts and full text of studies that met eligibility criteria were reviewed. Reference lists were also examined for any additional relevant studies not identified through the search.

RESULTS

Cancer patients have lower survival rates following CPR than patients with conditions other than cancer, and cancer patients who receive CPR in intensive care units have one-fifth the rate of survival to discharge of cancer patients who receive CPR in general wards. While the meta-analysis of studies published between 1967 and 2005 reported a lower survival to discharge for cancer patients (6.2%), more recent studies reported higher survival to discharge or to 30-day survival for these patients. Higher survival rates in more recent studies could originate with more "do not attempt resuscitation" orders for patients with end-stage cancer in recent years. Older age does not significantly decrease the rate of survival following CPR while the degree, the type, and the number of chronic health conditions; functional dependence; and multiple CPRs (particularly in advanced age) do reduce survival rates. Emergency Medical Services response time have a significant impact on survival following out-of-hospital CPR.

CONCLUSIONS

Survival after CPR depends on the severity of illness, type and number of health conditions, functional dependence, and multiple CPRs.

Two decades of British newspaper coverage regarding do not attempt cardiopulmonary resuscitation decisions: Lessons for clinicians

OBJECTIVE

To review UK newspaper reports relating to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions in order to identify common themes and encourage dialogue.

METHODS

An online media database (LexisNexis(®)) was searched for UK Newspaper articles between 1993 and 2013 that referenced DNACPR decisions. Legal cases, concerning resuscitation decisions, were identified using two case law databases (Lexis Law(®) and Westlaw(®)), and referenced back to newspaper publications. All articles were fully reviewed.

RESULTS

Three hundred and thirty one articles were identified, resulting from 77 identifiable incidents. The periods 2000-01 and 2011-13 encompassed the majority of articles. There were 16 high-profile legal cases, nine of which resulted in newspaper articles. Approximately 35 percent of newspaper reports referred to DNACPR decisions apparently made without adequate patient and/or family consultation. "Ageism" was referred to in 9 percent of articles (mostly printed 2000-02); and "discrimination against the disabled" in 8 percent (mostly from 2010-12). Only five newspaper articles (2 percent) discussed patients receiving CPR against their wishes. Eighteen newspaper reports (5 percent) associated DNACPR decisions with active euthanasia.

CONCLUSIONS

Regarding DNACPR decision-making, the predominant theme was perceived lack of patient involvement, and, more recently, lack of surrogate involvement. Negative language was common, especially when decisions were presumed unilateral. Increased dialogue, and shared decision-making, is recommended.

Resuscitation decisions for patients dying in the community: a qualitative interview study of general practitioner perspectives

BACKGROUND

Most patients dying at home do not have a Do Not Attempt Cardiopulmonary Resuscitation decision and may have inappropriate attempts at resuscitation made when they die.

AIM

To investigate how general practitioners think and feel about making and communicating Do Not Attempt Cardiopulmonary Resuscitation decisions for patients dying in the community.

DESIGN

Qualitative study using semi-structured interviews with general practitioners. The interviews were recorded and analysed using interpretative phenomenological analysis.

SETTING/PARTICIPANTS

Purposive sampling was used to recruit 10 general practitioners from urban and rural practices in Southern England and of various ages and experience. Interviews were carried out either in their home or in their practice.

RESULTS

General practitioners often wait until the patient has clearly deteriorated to communicate and document the Do Not Attempt Cardiopulmonary Resuscitation decision. They consider the chance of success of a resuscitation attempt, quality of life, dignity and the patient's and family's wishes. General practitioners feel they should discuss the decision with the patient but have anxieties about this. They vary widely in how much they guide patients and families in decision-making. Timing and the avoidance of conflict are important. Teamwork provides support in decision-making.

CONCLUSION

Resuscitation decisions are important in facilitating a peaceful death, but can be difficult for general practitioners to discuss. General practitioners might benefit from clearer guidance on when an attempt at resuscitation is unlikely to be successful, especially in non-malignant disease. Team discussions including Gold Standards Framework meetings can give confidence and support in making difficult end-of-life decisions.

Physicians' Knowledge of Cardiopulmonary Resuscitation Guidelines and Current Certification Status at the University Hospital of the West Indies, Jamaica

OBJECTIVE

To determine physicians' knowledge of cardiopulmonary resuscitation (CPR) guidelines at the University Hospital of the West Indies (UHWI), Jamaica, and their current certification status in basic life support (BLS), advanced cardiac life support (ACLS), paediatric advanced life support (PALS) and advanced trauma life support (ATLS).

METHODS

This was a cross-sectional study. A 23-item self-administered questionnaire was used to assess physicians practising at the UHWI, from the Departments of Anaesthesia, Surgery, Internal Medicine, Accident and Emergency, Obstetrics and Gynaecology and Oncology.

RESULTS

One hundred and forty-three (65%) of the targeted 220 physicians responded. There were 77 (55%) females and 41% of respondents were between ages 26 and 30 years. Knowledge of CPR guidelines was inadequate, as the median score obtained was 4.0 (interquartile range [IQR] 2-5) out of a possible eight. Physician seniority was inversely related to knowledge scores (p < 0.01). While 86% of all respondent physicians had been trained in BLS, only 46% were certified at the time of the study. Fewer (52%) were trained in ACLS with only 36% currently certified. Only 65% had been trained in the use of a defibrillator. Most knew the correct compression rate (78%), but only 46% knew the compressions to breaths ratio for both single and two-rescuer CPR. Only 42% of anaesthetists and 27% of emergency physicians were currently ACLS certified.

CONCLUSION

Physician knowledge of CPR protocols was suboptimal and current certification levels were low. Increased training and recertification is necessary to improve physician knowledge which is expected to result in improved performance of CPR.

Rate and predictors of successful cardiopulmonary resuscitation in end-stage liver disease

BACKGROUND

Cardiopulmonary resuscitation (CPR) after cardiac arrest in terminally ill patients is controversial. End-stage liver disease (ESLD) patients are unique from other terminally ill as they are generally younger and may be candidates for curative liver transplantation, but multiple studies have suggested poor outcomes when these patients require CPR. Predictors of success of CPR in ESLD have not been fully investigated, limiting end-of-life discussions.

AIM

The aim of this study was to quantify the rate and predictors of successful CPR in ESLD.

METHODS

We performed a retrospective chart review of patients with ESLD who received CPR from 2/2002 to 12/2013 at a single institution. Pre-cardiac arrest variables were collected for analysis as predictors of survival. Our primary outcome was survival to hospital discharge.

RESULTS

Of the 38 patients who underwent CPR, six survived to hospital discharge. When comparing those who survived to discharge with those who did not, we found no significant difference in age (p = 0.34), gender (p = 0.85), presence of ascites (p = 0.67), location at time of arrest (p = 0.39), concurrent GI bleeding (p = 0.48), and multiple individual lab values. Significant predictors of not surviving to hospital discharge were a model for end-stage liver disease (MELD) ≥ 20 (OR 6.0, p = 0.044) and presentation with a non-shockable rhythm (PEA/asystole) (OR 29, p < 0.001).

CONCLUSION

ESLD patients requiring CPR have worse outcomes as their MELD score increases. CPR in ESLD when MELD is <20 or with a shockable rhythm has a greater likelihood of success.

Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry

OBJECTIVE

To determine if earlier administration of epinephrine (adrenaline) in patients with non-shockable cardiac arrest rhythms is associated with increased return of spontaneous circulation, survival, and neurologically intact survival.

DESIGN

Post hoc analysis of prospectively collected data in a large multicenter registry of in-hospital cardiac arrests (Get With The Guidelines-Resuscitation).

SETTING

We utilized the Get With The Guidelines-Resuscitation database (formerly National Registry of Cardiopulmonary Resuscitation, NRCPR). The database is sponsored by the American Heart Association (AHA) and contains prospective data from 570 American hospitals collected from 1 January 2000 to 19 November 2009.

PARTICIPANTS

119,978 adults from 570 hospitals who had a cardiac arrest in hospital with asystole (55%) or pulseless electrical activity (45%) as the initial rhythm. Of these, 83,490 arrests were excluded because they took place in the emergency department, intensive care unit, or surgical or other specialty unit, 10,775 patients were excluded because of missing or incomplete data, 524 patients were excluded because they had a repeat cardiac arrest, and 85 patients were excluded as they received vasopressin before the first dose of epinephrine. The main study population therefore comprised 25,095 patients. The mean age was 72, and 57% were men.

MAIN OUTCOME MEASURES

The primary outcome was survival to hospital discharge. Secondary outcomes included sustained return of spontaneous circulation, 24 hour survival, and survival with favorable neurologic status at hospital discharge.

RESULTS

25,095 adults had in-hospital cardiac arrest with non-shockable rhythms. Median time to administration of the first dose of epinephrine was 3 minutes (interquartile range 1-5 minutes). There was a stepwise decrease in survival with increasing interval of time to epinephrine (analyzed by three minute intervals): adjusted odds ratio 1.0 for 1-3 minutes (reference group); 0.91 (95% confidence interval 0.82 to 1.00; P=0.055) for 4-6 minutes; 0.74 (0.63 to 0.88; P<0.001) for 7-9 minutes; and 0.63 (0.52 to 0.76; P<0.001) for >9 minutes. A similar stepwise effect was observed across all outcome variables.

CONCLUSIONS

In patients with non-shockable cardiac arrest in hospital, earlier administration of epinephrine is associated with a higher probability of return of spontaneous circulation, survival in hospital, and neurologically intact survival.

Palliative care in the emergency department

The Emergency Department (ED) is the place where people most frequently seek urgent care. For patients living with chronic disease or malignancy who may be in a crisis, this visit may be pivotal in determining the patients' trajectory. There is a large movement in education of emergency medicine physicians, hospitalists, and intensivists from acute aggressive interventions to patient-goal assessment, recognizing last stages of life and prioritizing symptom management. Although the ED is not considered an ideal place to begin palliative care, hospital-based physicians may assist in eliciting the patient's goals of care and discussing prognosis and disease trajectory. This may help shift to noncurative treatment. This article will summarize the following: identification of patients who may need palliation, discussing prognosis, eliciting goals of care and directives, symptom management in the ED, and making plans for further care. These efforts have been shown to improve outcomes and to decrease length of stay and cost. The focus of this article is relieving "patient" symptoms and family distress, honoring the patient's goals of care, and assisting in transition to a noncurative approach and placement where this may be accomplished.

Cardiopulmonary resuscitation among mechanically ventilated patients

PURPOSE

To evaluate the outcomes, including long-term survival, after cardiopulmonary resuscitation (CPR) in mechanically ventilated patients.

METHODS

We analyzed Medicare data from 1994 to 2005 to identify beneficiaries who underwent in-hospital CPR. We then identified a subgroup receiving CPR one or more days after mechanical ventilation was initiated [defined by ICD-9 procedure code for intubation (96.04) or mechanical ventilation (96.7x) one or more days prior to procedure code for CPR (99.60 or 99.63)].

RESULTS

We identified 471,962 patients who received in-hospital CPR with an overall survival to hospital discharge of 18.4 % [95 % confidence interval (CI) 18.3-18.5 %]. Of those, 42,163 received CPR one or more days after mechanical ventilation initiation. Survival to hospital discharge after CPR in ventilated patients was 10.1 % (95 % CI 9.8-10.4 %), compared to 19.2 % (95 % CI 19.1-19.3 %) in non-ventilated patients (p < 0.001). Among this group, older age, race other than white, higher burden of chronic illness, and admission from a nursing facility were associated with decreased survival in multivariable analyses. Among all CPR recipients, those who were ventilated had 52 % lower odds of survival (OR 0.48, 95 % CI 0.46-0.49, p < 0.001). Median long-term survival in ventilated patients receiving CPR who survived to hospital discharge was 6.0 months (95 % CI 5.3-6.8 months), compared to 19.0 months (95 % CI 18.6-19.5 months) among the non-ventilated survivors (p < 0.001 by logrank test). Of all patients receiving CPR while ventilated, only 4.1 % were alive at 1 year.

CONCLUSIONS

Survival after in-hospital CPR is decreased among ventilated patients compared to those who are not ventilated. This information is important for clinicians, patients, and family members when discussing CPR in critically ill patients.

Multiple in-hospital resuscitation efforts in the elderly

OBJECTIVES

The objective of this study was to determine the characteristics and survival rates of patients receiving cardiopulmonary resuscitation more than once during a single hospitalization.

DESIGN

We analyzed inpatient Medicare data from 1992 to 2005 identifying beneficiaries 65 years old and older who underwent cardiopulmonary resuscitation more than once during the same hospitalization.

MEASUREMENTS

We examined patient and hospital characteristics, survival to hospital discharge, factors associated with survival to discharge, median survival, and discharge disposition.

RESULTS

We analyzed data from 421,394 patients who underwent cardiopulmonary resuscitation during the study period. Four lakh thirteen thousand four hundred three patients received cardiopulmonary resuscitation once during a hospitalization and survival was 17.7% with median survival after discharge being 20.6 months. There were 7,991 patients who received cardiopulmonary resuscitation more than once during the same hospitalization; 8.8% survived the efforts, and median survival after leaving the hospital was 10.5 months. Patients who received more than one episode of cardiopulmonary resuscitation during a hospitalization were significantly less likely to go home after discharge. Greater age, black race, higher burden of chronic illness, and receiving cardiopulmonary resuscitation in a larger or metropolitan hospital were associated with lower survival among patients receiving cardiopulmonary resuscitation more than once.

CONCLUSIONS

Undergoing multiple cardiopulmonary resuscitation events during a hospitalization is associated with substantially reduced short- and long-term survival compared with patients who undergo cardiopulmonary resuscitation once. This information may be useful to clinicians when discussing end-of-life care with patients and families of patients who have experienced return of spontaneous circulation following in-hospital cardiopulmonary resuscitation but remain at risk for recurrent cardiac arrest.