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Don't quit too soon

Longer resuscitations associated with improved survival after cardiac arrest

From the December ACP Hospitalist, copyright © 2012 by the American College of Physicians

By Janet Colwell

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.”

Janet Colwell is a freelance writer in Miami.



Key facts

Below are some key particulars about the Sept. 5, 2012 Lancet study on duration of resuscitation efforts and survival after in-hospital cardiac arrest.

  • More than 64,000 cardiac arrest patients at 435 U.S. hospitals participating in the Get with the Guidelines Resuscitation registry between 2000 and 2008 were included.
  • The median duration of resuscitation before termination of efforts in non-survivors was measured as an indicator of the hospital's overall tendency for longer attempts.
  • Patients at hospitals in the quartile with the longest attempts (25 minutes [interquartile range, 25 to 28 minutes]) had a higher likelihood of return of spontaneous circulation (adjusted risk ratio, 1.12 [95% CI, 1.06 to 1.18]; P<0.0001) and survival to discharge (adjusted risk ratio, 1.12 [95% CI, 1.02 to 1.23]; P=0.021) than patients at hospitals with the shortest median resuscitation attempts (16 minutes [interquartile range, 15 to 17 minutes]).


Start early

Sooner, stronger chest compressions would improve hospital codes
By Stacey Butterfield

Longer resuscitation attempts may increase the chances of a code's success, but quality improvement is also much needed on the other end of the process—starting sooner.

“On average it takes between six and 10 minutes for [hospital clinicians] to achieve 100% certainty that somebody's in cardiac arrest,” Jason Persoff, MD, ACP Member, told attendees at the Rocky Mountain Hospital Medicine Symposium, held in Denver in September. That delay means that people who go into cardiac arrest on a plane or in a casino actually get a faster response than inpatients do.

“If it takes greater than one to two minutes for people to start chest compressions, patients die,” said Dr. Persoff, an assistant professor of hospital medicine at the University of Colorado Hospital in Denver. He offered a number of tips for improving the speed and success of inpatient code response.

First, don't wait to retrieve and make use of the code cart. “Part of the problem we have in hospitals is we want to get people hooked up to machines,” he said. “There's usually a flurry of activity, with very little focused on the patient.”

Pulse and rhythm analysis is a common time-waster at the start of a code, he said. “We spend so much…time trying to figure out whether or not somebody has a pulse,” Dr. Persoff said. “And we can't even do it.” He described studies showing that clinicians accurately judge the absence of a pulse about two-thirds of the time. Determining whether a patient is in ventricular fibrillation or asystole is even more difficult, and not really necessary, he added.

Time may also be wasted moving patients who've collapsed on the floor to a bed, which is actually the last place you want them to be. “The best place to do a code is on the floor,” said Dr. Persoff. “These beds are nothing more than a bunch of whoopee cushions…Studies have shown that we lose about 50% of our chest compression effectiveness if the patient is in a hospital bed.”

Another potential distraction is the patient's airway. “That's where most of the focus starts off on most cardiac arrests. In order to get patients to be in a shockable state, you need chest compressions first,” he said.

Chest compressions are really what a good code response is all about, according to Dr. Persoff. He urged clinicians not to be afraid to start them immediately. “If you're not sure if somebody is alive or dead and you want a barometer, start chest compressions. If they scream, run. If they don't scream, your hunch was probably right,” he said. “Has anybody ever seen anybody die because chest compressions were administered?”

Patients are more likely to survive, however, if their chest compressions are administered effectively. That means positioning yourself high enough above the patient to straighten your arms over his or her sternum. “Most of us in America are dealing with patients whose size makes it difficult to reach them,” Dr. Persoff noted.

Then, use gravity and abdominal muscles to push down, don't forget to recoil up off the patient (a common error, according to studies), and do all of it fast.

Fast means 100 compressions per minute, and it's important to note that any time spent not compressing the chest is included in that. “If you have hands off, waiting for intubation or analyzing the rhythm or trading rescuers, all of those interruptions count toward your total rate,” said Dr. Persoff.

Trade rescuers as quickly as possible, and don't let the issue of oxygen distract from chest compressions. “Circulation is number one. You can oxygenate all you want. If you're not perfusing the rest of the body, it doesn't matter,” he said. Putting non-rebreather masks over patients' faces rather than bagging them is usually the way to go. “You know what we typically do with a bag valve mask? We smother patients,” said Dr. Persoff. If a patient's gasping, that's a good sign, he noted.

Another time-waster may come as a surprise: making sure everyone's clear before shocking the patient. In a study, researchers (who hired some brave college students) found that touching the patient does not transfer enough current to cause harm. “Shock during compression is where we're going in resuscitation. By 2015, we're not going to be interrupting compressions for anything,” Dr. Persoff said.

That kind of change to recommendations should help rescuers put their primary focus where it belongs, on chest compressions. “Resuscitation should be simple,” said Dr. Persoff. “We make it too complex.”



2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. Circulation. 2010;122:18 (Suppl 3).

Goldberger ZD, Chan PS, Berg RA, Kronick SL, Cooke CR, Lu M, et al; for the American Heart Association Get With The Guidelines—Resuscitation (formerly the National Registry of Cardiopulmonary Resuscitation) Investigators. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet. Sept. 5, 2012. [PMID: 22958912]

Nolan JP, Soar J. Duration of in-hospital resuscitation: when to call time? Lancet. Sept. 5, 2012. [PMID: 22958913]

Yeung JH, Ong GJ, Davies RP, Gao F, Perkins GD. Factors affecting team leadership skills and their relationship with quality of cardiopulmonary resuscitation. Crit Care Med. 2012;40:2617-21. [PMID: 22732290]


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