In-Hospital Cardiac Arrest: How to Improve Survival? M. S

M. S

, A. B

, C. R

, C. L

, E. F

, M. D’O

, N. M

, S. B

, M. C

A cardiac problem is often the substrate for cardiac arrest (CA) (Table 1), but other diseases may be the underlying cause of sudden death, which in 75% of cases is due to ventricular fibrillation (VF) or ventricular tachycardia (VT), in 20% to bradyarrythmia, and in 5% to atrioventricular dissociation [1–5].

In Italy, CA strikes more than 60 000 people/year, with a 10% overall mortal- ity, 20% of which occurs in people with no signs of disease at all [1]. The chance of survival in case of CA strictly depends on the rapidity of interven- tion and on the correct execution of four basic, but fundamental steps – the

‘chain of survival’ [2]. The very first step is activation of the emergency sys- tem, in case the patient is unconsciousness (of course, this step involves acti- vating local emergency services). This is immediately followed by step 2, basic cardiopulmonary resuscitation, also known as basic life support (BLS) [3], which consists of a sequence of chest compressions and artificial ventila- tion. Defibrillation, the third step, is the only therapy able to stop VF/VT, the main cause of death in CA, while advanced cardiopulmonary resuscitation or advanced cardiac life support (ACLS) is the last step. Since its discovery, external defibrillation has been the cornerstone of emergency cardiac care (ECC) and the principal intervention in most successful resuscitations from full cardiac arrest.

A large body of out-of-hospital research [4, 6–9] shows that the rapidity of defibrillation is the most important determinant of survival in CA due to shockable arrhythmia.

Even though most CAs occur outside hospitals, the problem is still a major concern inside the hospital. In Italian hospitals, 85% of patients hospi-

1

Department of Cardiology, University ‘Federico II’, Naples;

Health Management,

University ‘Federico II’, Naples;

Intensive Care Unit, University ‘Federico II’, Naples,

Italy

talised in general medicine divisions die of sudden death, while mortality is less than 10% for patients hospitalised in intensive care units. Survival rates of CA patients outside critical care units remains about 15% at best, and sur- vival is consistently lower in general units than in critical care areas [10–15].

Explanations for this lack of progress usually involve comorbidity and unwitnessed arrests among patients in general units [14–20].

Defibrillation, in Italian hospitals, often occurs very late and not easily, as a result of either inadequate means, i.e. defibrillators, or the presence of architectural and institutional barriers, which may obstruct intervention. A defibrillator sometimes is available only in specific divisions of the hospital, and in some cases it is useless for technical reasons or due to the lack of experience of the staff. Furthermore, most of the time, intervention is car- ried out by a medical team from departments other than the cardiology department or the emergency room, and usually with a lengthy delay, which becomes even longer if, in the meanwhile, cardiopulmonary resuscitation (CPR) has not been carried out. General-medicine nurses are in the most dif- ficult position of anyone involved in the resuscitation effort. They are expected to respond immediately to unanticipated crises, unlike members of the emergency team, who have time to collect their wits while in transit to the scene. More importantly, several factors preordain the almost certain failure of attempts by general-medicine nurses to initiate basic CPR and defibrillation. Administering basic CPR has been shown to be difficult for all levels of health care providers, even in non-stressful classroom simulations [21, 22], so that in an actual in-hospital cardiac arrest administering CPR is even harder and thus takes longer. Furthermore, in the emotionally stressful Table 1. Heart disease that may cause sudden cardiac death in patients less than 30 years and in those older than 30 years. The most frequent disease that causes sudden death in patients ≤ 30 years is hypertrophic cardiomyopathy (50%), while the inci- dence of coronary artery disease is about 3–20%. In patients older than 30 years, the incidence of coronary artery disease is about 85%

Causes of sudden death % Causes of sudden death %

< 30 years > 30 years

Aortic stenosis 3–18 Coronary artery disease 85

Eisenmenger syndrome 15 Cardiomyopathy 10

Congenital cardiomyopathy 10 Valve disease 3

Hypertrophic cardiomyopathy 1–50 Electrical alternations 2 Right ventricular dysplasia 0–26

Mitral prolapse 1–24

Coronary artery disease 3–20

setting of an actual arrest, several preparatory steps must be taken: acquiring a respiratory barrier device, bringing a crash cart with cardiac board to the scene, and placing the cardiac board under the patient (a two-person task) [23, 24]. Starting ventilations, chest compressions, and defibrillation requires the coordinated actions of at least two people, because the use of pocket masks and most other barrier devices makes effective one-person CPR almost impossible. Given these obstacles, effective CPR is rarely initiated before the emergency team arrives [25]. Therefore, expecting general-medi- cine nurses to carry out an excessively complex and difficult task in an emer- gency situation may cause a state of ‘learned helplessness’ and increased dependence on the emergency team.

Early defibrillation programs can improve survival rates significantly by shortening the time from arrest to defibrillation. Improving the speed of in- hospital defibrillation may produce even better results (Table 2).

The purpose of an in-hospital emergency service is to decrease and pre- vent sudden death due to CA and to avoid the onset of its complications, e.g.

brain damage, kidney failure, in patients inside the entire hospital. The onset of complications vs recovery from CA are strictly related to the time of inter- vention, and it is well-known that survival chances decrease by 10% per minute [6], and brain damage occurs after 4–5 min of anoxia. In order to shorten intervention time and to avoid complications, the following is needed:

1. Information and sensitisation of the staff

2. Hospital staff training in CPR and defibrillation techniques

3. The presence of a hospital notification system for in-hospital emergen- cies

Table 2. Percentage of survival with and without immediate basic life support with defibrillation (BLS-D). Percent survival is strictly related to the immediate adminis- tration of BLSD. If BLSD does not occur immediately, and the advanced cardiac life support (ACLS) team arrives within 7–10 min of the cardiac event, survival is about 20%. If BLSD does not occur immediately and the ACLS team arrives later than 10 min after the cardiac event, survival is very low (2–8%) and is associated with irre- versible brain damage. The gold standard is early activation of the ACLS team and immediate BLS-D, which leads to a survival rate of 80–90%

Action Survival (%)

Early activation of ACLS team

No immediately BLS-D (7–10 min) 20

Early activation of ACLS team

No immediately BLS-D (> 10 min) 2–8 + brain damage Early activation of ACLS team

BLS-D immediately 80–90

4. Selection and creation of an operative team

5. Rational positioning of emergency trolleys inside the hospital 6. Standard procedures for all staff

7. Creation of a quality control system

8. Creation of a specific coordination centre for dealing with in-hospital emergencies

9. Retraining of the staff

The Naples Heart Project will try to achieve all nine goals, through instructional materials, courses, and the creation of permanent in-hospital emergency team.

The Naples Heart Project [26, 27] began on July 2001, and since then it has created about 835 first responders among the hospital staff, 440 of whom are physicians (fully trained or still in training), 310 nurses, and 85 members of the administrative staff. Our primary purpose is to train all general-medi- cine nurses, physicians, and other working staff which amounts to more than 3000 people, in BLS and defibrillation (BLS-D). To meet this goal, we have organised courses [11] combining theory and practice, so that the partici- pants can develop psychomotor abilities and automatic response patterns which guarantee that the rescuer provides the best possible aid. Both the instructional material and the courses emphasise the rational basis of the

‘chain of survival’ and train participants in basic CPR and defibrillation

techniques courses. A practical part is intended to make the rescuer feel

more comfortable when aiding the victim. The courses are tailored with

respect to material, duration, and final examination according to the partici-

pants, with the easiest and safest interventional approaches taught to non-

medical personnel. All courses are held during one day. The course for

administrative staff is 6 h in duration and is equally divided between theory

and practice. Participants are trained to use a semiautomatic defibrillator,

without a monitor for ECG, and with a voice system that guides the rescuer

through the steps of the ‘chain of survival.’ Semiautomatic defibrillators are

the only ones that non-medical personnel are allowed to use, as specified by

Monteleone’s Law, passed on April 3, 2001 [7]. Courses for nurses (Fig. 1) are

8 h long, contain more information on physiopathology of CA, and provide

training in all BLS techniques and on defibrillator usage. The courses for

physician are 10 h long and provide more detailed information on the phys-

iopathology, epidemiology, and specific patterns of CA. For all groups,

biphasic wave defibrillators [8] are used, as they require less energy than

monophasic defibrillators and have a comparable effectiveness at a lower

energy level. All the three groups take a final test, consisting of basic ques-

tions and without the requirement to interpret an ECG. Even though all par-

ticipants have shown interest in the theory and practice, not all achieved a

good grade at the final test. We had to re-enrol 40 candidates in another ses-

sion and then re-test them, but positive results were achieved the second time. Since no one practices either BLS techniques or the use of defibrillators daily (with some exception), the course is repeated at least once a year and will be offered on a continual basis, including retraining after 1 year, for all the personnel.

The Naples Heart Project training centre also provides support for ACLS courses, with the goal of creating a team that offer ACLS anytime and any- where in the hospital. ACLS courses are held over two 8-h days, during which physicians are trained in using manual defibrillators with external pacing capacity, administering drugs for the treatment of tachyarrhythmias and bradyarrhythmias, and airway intubation.

As of this writing, several sessions with 25 participants per day have been organised. The number of participants has increased from July 2001 to May 2003 (Figs. 2, 3).

The Naples Heart Project was based on a feasibility study of in-hospital emergency services. The study evaluated and analysed: type of institution, departmental and institutional dislocation, internal practicability (architec- tural features and preferential behaviours), staff number and distribution, presence of an emergency notification system, and instruments available.

The aim is to find the best solution in order to make the chain of survival as fast and effective as possible, in every place, moment, and condition in the hospital.

Fig. 1. Naples Heart Project BLSD first-responder course. Basic life support with defib-

rillation (BLS-D) training of nurses

0 100 200 300 400 500 600 700 800 900

July 2001 Dec 2001 Jul 2002 May 2003

Fig. 2. Naples Heart Project BLSD first responders. The project began on July 2001, and since then it has already created about 835 BLS-D first responders among the hospital staff. Of these, 440 are specialist physicians and physicians in training, 310 are nurses and 85 are in the administrative staff

0 20 40 60 80 100 120

July 2001 Jul 2002 Dec 2002 May 2003

A

Fig. 3. Naples Heart project ACLS responders. The project’s training centre provides ACLS courses in order to create an ACLS team able to respond anytime and anywhere in the hospital. Currently, 120 ACLS responders have been trained

ACLS responders

University ‘Federico II’ General Hospital has about 1200 beds and is divided into separate and independent institutes. Everyday, several thousand people, including patients, physicians, technical and administrative staff, vis- itors, and students spend time in the general hospital. It is therefore neces- sary that anyone inside the general hospital is familiar with all the hospital emergency programs. In order to make this possible, we have created a brochure of the hospital emergency services, for patients and visitors, to be distributed in waiting rooms and at the main entrance. In addition, posters have been placed in every institute; meetings and conferences directed to potential BLSD providers, i.e. physicians, nurses, administrative and techni- cal staff, have been organised. We are also planning to install a series of road signs (Fig. 4) throughout the hospital providing directions to the nearest defibrillation point.

The project also provides a rational distribution of semiautomatic defib- rillators and accompanying materials, in order to have a defibrillator and a fully organised trolley for emergencies available on all floors, so that the delay due to access and transport of material is greatly decreased; further- more it has been proposed to periodically check the emergency trolleys and other materials and to keep a checklist.

AED

AUTOMATIC EXTERNA L DEFIBRILLATOR

NAPLES BLSD HEART PROJECT

Fig.4. Defibrillation point. The Naples

Heart Project provides a series of road

signs throughout the hospital providing

directions to the nearest defibrillation

point

The project will be administered and coordinated by an in-hospital emer- gency system leader, who is charged with mediating contacts between the emergency team, training centre, and BLSD and ACLS providers on the one hand, and the emergency coordination group (composed of a general man- ager, a medical manager, and a nursing manager) on the other.

In conclusion, an in-hospital emergency has to be dealt with not as a chaotic chain, but like an organised procedure with standard protocols familiar to all staff. It is therefore necessary to organise training following a well-defined program with a fixed term; training courses must provide theo- retical and practical knowledge for responding to emergency situations.

The Naples Heart Project, consisting of courses for BLS-D and ACLS responders (physicians, nurses, and staff in the general hospital), is close to achieving this goal. It is the first project of its kind in Italy, and it lays the basis for the development of a medical emergencies culture able to cope with both in and out of hospital scenarios.

References

1. Anonymous (1988) Vital statistics of the United States, 1988. National Center for Health Statistics, 2A, Hyattsville, MD, USA

2. Cummins RO, Ornato JP, Thies WH, Pepe PE (1991) Improving survival from sud- den cardiac arrest: the ‘chain of survival’ concept. A statement for health professio- nals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 83(5):1832–1847

3. Anonymous (1992) Guidelines for cardiopulmonary resuscitation and emergency cardiac care, I: introduction. JAMA 268:2172–2183

4. Myerburg RJ, Kessler KM, Zaman L et al (1982) Survivors of prehospital cardiac arrest. JAMA 247:1485–1490

5. Bayes de Luna A, Coumel P, Leclercq JF (1989) Ambulatory Sudden Cardiac Death : Mechanism of production of fatal arrythmya on the basis of data from 157 cases.

Am Heart J 117:151–159

6. Grotta JC (1996) The importance of time. In: proceedings of the national Symposyum on rapid identification and treatment of acute stroke. The national Institute of Neurological disorders and stroke, pp 1–9

7. Stoddard FG (1996) Public Access Defibrillation comes of age. Currents. Winter 7:1–3

8. Kerber R, Becker L, Bourland J et al (1997) Automatic external defibrillators for public access defibrillation: recommendation for specyfing and reporting arrythmya analysys, algorithm performance, incorporating new wave forms, and enhancing safety. Circulation 95:1677–1682

9. Capucci A, Aschieri D, Piepoli Mf et al (2002) Tripling survival from sudden cardiac arrest via early defibrillation without traditional education in cardiopulmonary resuscitation. Circulation 106(9):1065–1070

10. Skrifvars MB, Castren M, Kurola J, Rosenberg PH (2002) In-hospital cardiopulmo-

nary resuscitation: organization, management and training in hospitals of different

levels of care. Acta Anaesthesiol Scand 46(4):458–463

11. Anonymous (2000) Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 6: advanced cardiovascular life support: sec- tion 4: devices to assist circulation. The American Heart Association in collabora- tion with the International Liaison Committee on Resuscitation. Circulation 102(8 Suppl):I105–I111

12. Handley JH, Monsieurs KG, Bossaert LL (2001) European Resuscitation Council Guidelines 2000 for adult Basic Life Support. Resuscitation 48:199–205

13. Monsieurs KG, Handley JH, Bossaert LL (2001) European Resuscitation Council Guidelines 2000 for Automated External Defibrillation. Resuscitation 48:207–209 14. McGrath PB (1987) In-house cardiopulmonary resuscitation-after a quarter of a

century. Ann Emerg Med 11:1365–1368

15. Dans PE,Nevin KL, Seidman CE, McArthur JC (1985) Inhospital CPR 25 years later:

why has survival decreased? South Med J 78:1174–1178

16. Tunstall-Pedoe H, Bailey L, Chamberlain DA et al (1992) Survey of 3765 cardiopul- monary resuscitations in British hospitals (the BRESUS study: methods and overall results). BMJ 304:1347–1351

17. Lazzam C, McCans JL (1991) Predictors of survival of in-hospital cardiac arrest.

Can J Cardiol 7(3):113–116

18. Bedell SA, Delbanco EF, Cook EF, Epstein FH (1983) Survival after cardiopulmo- nary resuscitation in the hospital. N EngI J Med 309:569–576

19. Hershey CO, Fisher L (1982) Why outcome of cardiopulmonary resuscitation in general wards is poor. Lancet 1:31–34

20. Grauer K, Cavallaro D (1993) ACLS-A comprehensive review. Mosby Lifeline, St.

Louis

21. Berden HJ, Hendrick JM, van Doornen JP et al (1993) A comparison of resuscita- tion skills of qualified nurses and ambulance nurses in The Netherlands. Heart Lung 22(6):509–515

22. Flesche C, Neruda B, Breuer S, Tarnow J (1994) Basic cardiopulmonary resuscita- tion skills: a comparison of ambulance staff and medical students in Germany.

Resuscitation 28:S25 (abs)

23. Kaye W, Mancini ME, Giuliano KK et al (1995) Strengthening the in-hospital chain of survival with rapid defibrillation by first responders using automated external defibrillators: training and retention issues. Ann Emerg Med 25(2):163–168 24. Brown J, Latimer-Heeter M, Marinelli A et al (1995) The first 3 minutes: code pre-

paration for the staff nurse. Orthop Nurs 14(3):35–40

25. Brenner BE, Kauffman J (1995) Response to cardiac arrests in a hospital setting:

Delays in ventilation. Circulation 92:i–761 (abs)

26. Santomauro M, Ottaviano L, Borrelli A et al (2002) Organization Project for Precocious Semiautomatic in Hospital Defibrillation (heart project). Progress in Clinical Pacing, Roma, December 3–6, 2002, p 46

27. Santomauro M, Ottaviano L, Borrelli A et al (2003) Sudden cardiac death preven-

tion through hospital early defibrillation Naples experience. PACE 26:S186