Don't quit too soon

Findings from a recent study may change practice.

After reading the results of a recent study suggesting that longer cardiopulmonary resuscitation (CPR) efforts might help more patients survive cardiac arrest, hospitalist Dana P. Edelson, MD, gathered her team at the University of Chicago's Medical Center to discuss the potential effect on practice.

“It is a very important paper with a big impact, and it flies in the face of some of our prior notions,” said Dr. Edelson, chair of the University of Chicago Medical Center's CPR committee and co-author of the 2010 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care. She noted that thus far there has been a dearth of evidence to guide clinicians on the optimum length for resuscitation efforts. “It's hard to be prescriptive about length of resuscitation, but what this study does is debunk the theory that 20 minutes is enough,” she said.

Photo by Thinkstock
Photo by Thinkstock.

Published online Sept. 5 in the Lancet, the observational study is the largest of its kind, involving 435 U.S. hospitals participating in the Get with the Guidelines Resuscitation registry. By analyzing length of resuscitation attempts among non-survivors, researchers found that patients at hospitals with the longest median resuscitation times (25 minutes) were more likely to survive a cardiac arrest than patients in hospitals with the shortest median times (16 minutes). Notably, patients who survived longer resuscitations were not more likely to suffer neurological damage.

For Dr. Edelson, whose hospital participates in the registry, the data were reassuring because the University of Chicago's median time of almost 30 minutes placed it in the highest quartile of participating hospitals. For hospitals that don't participate in a registry or track their data, the study should be a wakeup call to investigate where they fall in the spectrum, said Harlan M. Krumholz, MD, a cardiologist at Yale University and one of the authors of the Lancet study.

“When you're involved in a code, you always think you're giving the patient every opportunity to be resuscitated and you're always convinced that you're ending it when there's no chance for survival,” he said. “But this paper shows there is a lot of variation, and the implication is quite powerful because in hospitals ending [resuscitation] early, there might be people dying who otherwise might have been saved.”

Where does your hospital stand?

Now that the information is out there, hospitalists should be discussing the findings and reflecting on their own patterns of performance, said Dr. Krumholz, who is director of Yale's Center for Outcomes Research and Evaluation.

“As a hospital, are you at the long end or short end of the spectrum? How do your outcomes compare with others?” he asked. “This is information that should immediately be funneled into quality improvement efforts in the hospital to see if there are opportunities for improvement.”

As a first step, hospitals “should audit their cardiac arrests and benchmark outcomes,” said a commentary accompanying the Lancet study. And if your hospital proves to be on the lower end of the spectrum in terms of resuscitation times, “it might be worthwhile to try for a little longer,” especially in cases where the cause of the cardiac arrest is asystole. The study showed that this subgroup of patients benefited the most from prolonged resuscitation efforts.

The study authors declined to recommend a specific cutoff time for resuscitation, acknowledging the importance of clinical judgment, but they did note that their findings “suggest that standardization of a minimum length for resuscitation attempts could improve survival.”

“When you think about the implications of extending efforts for 10 minutes, say, once a team is there and efforts have started, the utilization of resources is fairly low,” said Brahmajee K. Nallamothu, MD, a cardiologist at the University of Michigan and one of the study's authors.

Keep in mind, though, that extending resuscitation times should be part of a larger quality improvement effort, said Dr. Nallamothu, because it's likely that hospitals that spend longer on resuscitation are also more likely to reliably follow guidelines and protocols and provide more comprehensive care.

“It will be interesting for hospitals to see if there's something about longer resuscitation efforts that appears to correlate with higher quality,” he said. “We suspect it is a combination of aspects of care that are associated with better outcomes.”

Improving the system for survival

While the study initially may seem to contradict previous thinking, it makes sense when you interpret its central observation (longer resuscitations associated with improved survival) as a “surrogate” for better overall quality of care, said John M. Field, MD, a cardiologist at Penn State Hershey Heart and Vascular Institute in Hershey, Pa., and co-author of the 2010 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care.

“If you are in the lowest quartile, the inappropriate thing to do is to say ‘We're going to increase our median time by nine minutes,’ because that [alone] probably won't improve outcomes,” he said. “Instead, go back and review the quality of resuscitations during the code—it's really the system for survival that matters, and not any one specific intervention.”

Dr. Field recommended, for example, observing teams during cardiac resuscitations for quality of chest compressions and holding a team debriefing session following each cardiac arrest. Also, he suggested reviewing the quality of post-cardiac arrest care and whether any specific interventions, such as brain hypothermia, were undertaken.

According to the commentary in the Lancet, “Hospitals that offer a comprehensive package of care after cardiac arrest (including the use of therapeutic hypothermia and percutaneous coronary intervention), which improves survival, might have a more aggressive approach to resuscitation than do hospitals that do not offer such comprehensive strategies.”

Large hospital systems and academic medical centers tend to have more resources to fund comprehensive programs, but all hospitals can perform basic and advanced life support and have the potential to improve outcomes, said Dr. Field.

“Return of spontaneous circulation or pulse for 30 minutes after the patient has been resuscitated achieves the first benchmark [of the study]—up to that point, all hospitals should be able to [care for] the patient,” he said. “Then if the patient needs advanced care, the hospital can make the decision to manage it at their facility or transfer the patient to a regional center for post-cardiac arrest care.”

Leadership skills should be another central component of training for cardiopulmonary teams, according to one study that examined the relationship between leadership skills and quality of resuscitation in cardiac arrest simulations. The study, published in the September 2012 Critical Care Medicine, found an association between teams with good leadership skills, such as coordination, cooperation and communication, and shorter pre-shock pauses, shorter hands-off ratio, and better overall performance.

“Cardiac arrests are very chaotic, high-stakes events and require a group of individuals who don't typically work together to come together and take care of a very sick patient,” said Dr. Nallamothu. “Organizational culture, safety and leadership are often overlooked because they are difficult to study, but they are incredibly important.”

Unfortunately, physicians typically don't get much training in how to lead teams, he added. “But we're often thrown into situations where it would make a difference.”

At the University of Chicago, leadership training is one important element in an ongoing quality improvement program aimed at achieving the best outcomes possible, said Dr. Edelson. Teams of physicians, nurses, pharmacists and respiratory therapists undergo simulation training, which includes leadership training, and attend monthly debriefing sessions to review data to learn from prior events.

“We collect a cardiopulmonary quality transcript from every resuscitation,” said Dr. Edelson. “We know every chest compression performed, how deep it was, what the rate was, and how often they paused.” Some of that data are then entered into the Get with the Guidelines registry for tracking and benchmarking purposes, she added.

However, it's a mistake to rely exclusively on specially trained teams, she said. A full training program should include everyone in the hospital.

“We know that the first couple of minutes of a resuscitation are the most important, so making sure that people who are on the scene are able to defibrillate and do high-quality CPR is crucial,” she said. “You can have the best team in the world but the patient's survival is hugely dependent on the people who are there in the first three minutes.”