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From: Contemporary Cardiology: Cardiopulmonary Resuscitation Edited by: J. P. Ornato and M. A. Peberdy © Humana Press Inc., Totowa, NJ
32 In-Hospital Resuscitation
Mary Ann Peberdy,
MD,
FACCCONTENTS
INTRODUCTION
THE IN-HOSPITAL CHAIN OF SURVIVAL
THE NATIONAL REGISTRY OF CARDIOPULMONARY RESUSCITATION
REFERENCES
INTRODUCTION
Resuscitation began in the hospital setting nearly 40 years ago and little has been done since that time to provide a critical evaluation of the process by which resuscitation is performed. Recent regulatory and federal guidelines are forcing hospitals to assess both process and outcome variables to improve the care given to victims of cardiac arrest (CA).
The purpose of this chapter is to review process evaluation issues for hospital-based resuscitation programs and to describe the National Registry of Cardiopulmonary Resus- citation (NRCPR) as a tool for enhancing quality improvement and resuscitation science in the hospital.
THE IN-HOSPITAL CHAIN OF SURVIVAL
The American Heart Association (AHA) first developed the Chain of Survival con- cept in 1991 to facilitate a timely and appropriate response to victims of a CA (1). The now familiar chain consists of the four links of early access, early basic life support (BLS), early defibrillation, and early advanced cardiac life support (ACLS). Pre-hos- pital emergency medical services (EMS) systems have paid meticulous attention to strengthening each link in the chain of survival, specifically with respect to early defibrillation, and communities have been rewarded with improved survival over the past decade. Hospitals, however, have been rather reluctant to critically evaluate their process of providing resuscitation efforts in order to assure that all the links in the chain are optimized and occurring in a timely manner. Some of this may be the belief that because hospitals are filled with health care providers, they automatically have an optimized response. Many people familiar with hospital-based resuscitation would disagree because many physicians and nurses have minimal advanced life support (ALS) training and use these skills very infrequently. Another possibility may be that resuscitation practices are often “orphaned” within a hospital system. Providing an
adequate response is a hospital-wide effort and requires hospital wide support. Although many hospitals have a few champions for the cause, most lack overt organizational backing for critical process evaluation and enhancement. The last few years have seen the beginning of a shift toward process and outcome improvements for in-hospital resuscitation but the trend is slow to take hold and is complicated by what appears to be reluctance to use strategies that have been successful in the pre-hospital setting, such as first responder automatic external defibrillator (AED) use to deliver early defibrillation.
Overall survival from cardiopulmonary arrest in the hospital setting has remained con- stant over the past 30 years with reports quoting a range from 3 to 27%, depending on the criteria and definitions used for inclusion criteria and outcomes (2–4).
Although one could argue the impact of acute comorbidities in the hospital popula- tion, it is concerning that survival has never improved in this setting despite significant advances in technology that have translated into improved survival in out-of-hospital CA populations. This fact alone, independent of the need for quality review, should prompt hospitals to critically evaluate the process by which they perform resuscitation.
Specific attention should be paid to both the process and clinical issues in order to identify issues that could potentially impact survival.
The AHA published its Recommended Guidelines for Reviewing, Reporting, and Conducting Research on In-Hospital Resuscitation: The In-Hospital Utstein Style in 1997 (5). This scientific statement defined a set of data elements deemed as essential or desirable for documenting in-hospital CA responses. It was developed as a mechanism for international standardization of process evaluation and reporting for in-hospital resuscitation. By encouraging hospitals to use uniform definitions and methodology, the Utstein template provides greater accuracy in comparing and contrasting data from individual hospitals as well as across multiple studies. This document was the first widespread effort to encourage hospitals to systematically evaluate resuscitation efforts and outcomes
The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) placed further emphasis on hospital resuscitation practices with the publication of new regulations in 1998. As of January 1, 2000 the JCAHO required all accredited hospitals in the United States to have effective resuscitation services available throughout the hospital and to collect outcomes data. The JCAHO regulation Tx.8 states the following:
1. Appropriate policies, protocols, procedures, and processes governing the provision of resuscitation services
2. Appropriate equipment placed strategically throughout the hospital close to areas where patients are likely to require resuscitation services
3. Appropriate staff trained and competent to recognize the need to and use of designated equipment in resuscitation efforts
4. Appropriate data collection related to the process and outcomes of resuscitation 5. Ongoing review and outcomes related to resuscitation in the aggregate to identify oppor-
tunities for improvement in resuscitation efforts
This new set of standards provides an opportunity for hospitals to pay specific atten- tion to the process of resuscitation and re-enforces the fact that resuscitation responses are a system-wide effort. By evaluating policy, protocols, and procedure hospitals are forced to review the way resuscitation efforts are carried out, specifically with respect to making sure that all populations are covered (inpatient, outpatient, visitor, adult, and pediatric) and that the response process chosen does everything that it can to strengthen the chain of survival in the hospital community. The second standard mandates that
appropriate equipment be placed throughout the hospital and should stimulate an analyti- cal approach by individual institutions to assure they have the most appropriate equip- ment for providing prompt, first responder, BLS with early defibrillation followed by ALS. The equipment must be appropriate for the population at potential risk for CA. The third regulation involves documenting competency for persons responding to CA. This is the fist time that hospitals have been held accountable for assuring skills retention in this area. There are many approaches toward training and competency testing, ranging from traditional classroom educational models to computer-based scenario testing that can be done on the practitioners own time schedule at the convenience of their own computer. Training and skills documentation can be uniquely designed to fit the needs and resources of individual institutions. Hospitals are now required to collect data related to both the process and outcomes of resuscitation. Never before have hospitals been mandated to perform periodic quality review of the entire process of resuscitation efforts.
If done honestly and correctly, hospitals should critically evaluate every link in the chain of the resuscitation process. Examples of questions to be asked include the following:
• Is there a team response? Who should be on that team?
• Are the right people responding?
• How are responders trained to handle medical emergencies?
• How can we best provide early defibrillation?
• How does the team get summoned?
• How is the telepage operator involved?
• If a pager system is used, is there a lag time?
• How far does the team have to travel to cover the resuscitation area?
• What are the response-time intervals to the arrival of key personnel and interventions?
• How is time documented and is time documentation accurate?
• Is event documentation accurate?
• Are proper BSL and ALS guidelines being followed?
• What policies are in place regarding the “do not attempt resuscitation” (DNAR) decision pre-, or even postarrest?
Each area of the hospital that participates in the resuscitation process, such as nursing, pharmacy, anesthesia, respiratory therapy, central supply, medicine, surgery, profes- sional education, and telepage, needs to evaluate the role it plays and develop the stron- gest process possible. For this to be done effectively and efficiently, a multidisciplinary committee should be formed to provide oversight and direction to this entire process.
Because resuscitation services are used by everyone in the hospital and typically owned by no one, it is important that the committee have the resources and authority to do its job well.
THE NATIONAL REGISTRY
OF CARDIOPULMONARY RESUSCITATION
The AHA’s NRCPR is a prospective, multisite registry of in-hospital resuscitation.
The registry was developed by AHA volunteers with expertise in cardiology, emergency medicine, adult and pediatric critical care medicine, nursing administration, and nursing education, and is based on the in-hospital Utstein guidelines for data collection. One of the unique features of the NRCPR is that it provides explicit definitions for every data element. This not only allows for interfacility comparison, but also permits data from numerous facilities to be combined and evaluated for trends in process, treatment, and outcomes. The goals of the NRCPR are to provide a standardized mechanism for quality
data collection and review, to give local hospitals a mechanism to critically evaluate resuscitation process issues, treatment patterns, and outcomes, and to provide an ongoing data source for the development of evidence-based guidelines for resuscitation practices.
Participating hospitals join the NRCPR voluntarily and have specially trained coordina- tors to enter information about each CA into a computer database. Data is submitted by either diskette or encrypted internet transfer to the central data repository. Each patient is assigned a unique code and no specific patient identifiers are transferred. Hospitals receive extensive quarterly reports on their own facility data along with comparisons to the national dataset. These reports provide hospitals with a comprehensive mechanism to meet JCAHO requirements for hospital-based resuscitation review.
The data set contains the following six major categories of variables:
1. facility data.
2. patient demographic data.
3. pre-event data.
4. event data.
5. outcome data.
6. quality improvement data.
Inclusion criteria are any adult (>18 years) or pediatric (<18 years) patient, visitor, employee, or staff who experience a resuscitation event that requires chest compression and/or defibrillation, elicits an emergency response by facility personnel, and has a resuscitation record completed for review. Events that begin outside of the hospital, in the neonatal intensive care unit (ICU), or occur in newborns in the delivery room are excluded.
Peberdy et al. (6) recently published the largest descriptive report of in-hospital resus- citation events in adults from the NRCPR data set. The report includes 14,720 CAs from 207 hospitals over a 2.5-year period. Demographic data of adults experiencing a CA in the hospital are 57% male with a mean age of 67.6 + 15.4 years. Eighty percent of arrests occurred on the medical services, being equally divided between cardiac and noncardiac.
Forty-eight percent of arrests occurred in the ICU, 32% on general inpatient wards, 11%
in the emergency department (ED), 4% in diagnostic areas, and 2% in the operating room. Less than 1% occurred in ambulatory care or visitors areas, although hospitals are required to have adequate responses for resuscitation in these populations. Knowledge of the likely service and location could have significant impact on staffing, training, and equipment placement.
The most common pre-existing conditions for adults experiencing CA in the hospital are myocardial infarction (36%), respiratory insufficiency (35%), congestive heart fail- ure (34%), arrhythmia (29%), renal insufficiency (29%), diabetes mellitus (28%), and pneumonia (24%). Eighty-six percent of CA events are witnessed and/or monitored with 66% being both witnessed and monitored, 11% witnessed and not monitored, and 9%
monitored and not witnessed.
The three most common nonexclusive precipitating issues present in the hour before the arrest are cardiac arrhythmia (49%), respiratory insufficiency (37%), and hypoten- sion (32%). Although cardiac arrhythmias may occur suddenly without much warning, they are often the result of prolonged respiratory insufficiency or hypotension. More than two-thirds of adult CAs in the hospital are precipitated by disturbances that, if identified and intervened on promptly, may prevent the CA from occurring. This stresses the importance of having nurses and physicians trained to recognize and intercede in the pre-arrest period to prevent the occurrence of a full CA. Some hospitals have employed
medical emergency teams specifically trained in the pre-arrest crisis intervention to be summoned to assist with the care of a patient before the code team is needed (7–11).
Some of these teams have been able to actually decrease the number of CAs that occurred and have also improved survival.
The first pulseless rhythm documented for adult CA is ventricular fibrillation/ven- tricular tachycardia (VF/VT) in 25%, pulseless electrical activity (PEA) in 30%, and asystole in 36%. The prevalence of VF as an initial rhythm is surprisingly low in the hospital setting. This is in contrast to the majority of out-of-hospital CAs that occur with a continuous monitor in place, in monitored cardiac rehab, and in some public access defibrillation programs such as the casinos (12,13). Although the occurrence of VF as a presenting rhythm diminishes over time, the fact that 86% of events were monitored or witnessed in the hospital suggests that a delay in rhythm recognition does not solely account for the infrequent presence of VF as the initial arrest rhythm. In-hospital CA may have different mechanisms and pathophysiology than prehospital arrest. This may ac- count for the predominance of asystole and PEA in this population compared to prehospital arrests.
Overall return of spontaneous circulation was 44% with overall survival-to-hospital discharge of 17%. Broken down by presenting rhythm, VF/VT carries a 35% survival rate to hospital discharge, in which survival from asystole and PEA are 10% each. The higher percent of asystole and PEA patients having a lower survival further dilutes the better survival in the comparatively smaller VF group. Of those patients that survived their initial arrest but died in the hospital, 63% were declared DNAR status after their index event, and 43% of these had life support actively withdrawn. The aggressiveness with which an individual hospital withholds resuscitation efforts and withdraws care can significantly impact survival and have tremendous influence on the outcomes of clinical trials requiring survival-to-hospital discharge as an endpoint. The average hospital length of stay is nearly 2 weeks for survivors and less than 2 days for those who die in the hospital. The majority of those being declared DNAR are being done so very early after their index event, perhaps even before meaningful recovery could be expected. Further investigation is needed to determine DNAR practice patterns and to identify accurate predictors of nonsurvival after initial CA.
Fifty-one percent of patients surviving a pulseless index arrest were discharged to home. More than 30% of survivors were discharged to a rehabilitation facility or a skilled nursing facility when less than 6% had lived in such a facility prior to their arrest. It is reassuring however, that 86% of patients with a Cerebral Performance Category-1 (CPC- 1) at the time of admission had a CPC-1 at the time of discharge.
AEDs in the Hospital
Despite the fact that only 25% of pulseless CAs in the hospital are caused by VF, survival in this group is much better than when asystole or PEA are the presenting rhythms (35 vs 10% respectively). Hospitals must assure that defibrillation can be delivered promptly in order to appropriately treat the small group of arrest patients who have the best chance of survival. Survival from VF arrest is inversely related to the time to shock. This is true for both pre-hospital and in-hospital settings. Data from witnessed arrests during cardiac rehabilitation (14) or induced in the electrophysiology labora- tory (15) report survival rates of more than 90% and nearly 100%, respectively.
Valunzuela et al. (13) reported a 74% survival-to-hospital discharge from out-of-hos- pital CA when on-site lay first responders provide defibrillation in less than 3 minutes.
Caffrey et al. (16) found an overall survival rate of 66% in victims of VF arrests in the Chicago airport public access defibrillation (PAD) system. Data from NRCPR has correlated improved survival with shorter time to shock intervals. The survival rate was 38% when the first shock was delivered within 3 minutes, compared to only 21% when delivery was reported as more than 3 minutes. Even though many communities and public venues have markedly improved survival from CA by using AED technology and implementing PAD systems, hospitals have been slow to adopt the concept of having hospital first responders deliver lifesaving defibrillation. Inside the ICU, nurses often initiate CPR and provide defibrillation based on rhythm recognition and standing order. Outside of the ICU, nurses and other first responders perform CPR but typically must await the arrival of a physician to provide defibrillation. In-hospital use of AEDs by non-ICU nurses and other first responders was first described in 1995 (17,18) and 8 years later only 33% of NRCPR-participating hospitals reported having AED capa- bility anywhere in their institutions. Critical evaluation of timing documentation, pro- cess issues, outcomes, and a willingness to explore different approaches to enhance early defibrillation are necessary for hospitals to begin to improve survival from VF arrest.
Outpatient Facilities
Medical practice in the United States is experiencing a continuous shift toward outpa- tient care. Both the volume and acuity of patients seen in the ambulatory care setting has increased dramatically since the 1990s. Numerous diagnostic and therapeutic procedures performed previously on in-patients are now occurring routinely on outpatients. Because of the use of conscious and deep sedation and increasing numbers of invasive and interventional procedures, outpatient facilities are faced with higher risk patients than in the past. The JCAHO mandates that a similar standard of care must be provided through- out all areas of the hospital, including ambulatory care facilities. This does not mean that the exact process for responding to CA be the same throughout but rather that a similar level of care be provided in all areas. The mechanism to achieve that level of care may differ by location. This is extremely important when designing a resuscitation response for hospital-affiliated outpatient centers.
Many hospital-affiliated outpatient facilities consist of several distinct buildings that may or may not be physically connected to the in-patient hospital complex or the ED.
Providing a timely, appropriate, and consistent response to victims of CA or other medi- cal emergencies can be challenging. Emergency response options for these areas include calling the in-patient code team, having an on-site response team in the ambulatory care areas, calling 911, or a combination of these. There are also growing numbers of satellite offices in remote locations not in close proximity to the main hospital. The only viable response to emergencies in these areas is to have an on-site response team and/or to call 911. Healthcare Finance Administration regulations state that hospitals must be able to respond to all persons experiencing a medical emergency on the premises. This requires a prompt and proper response for pediatric and adult patients, visitors, and staff.
Suitable training and equipment are necessary to respond appropriately to cardiorespi- ratory arrest and other potentially life-threatening medical emergencies. Immediate, advanced life support capable transportation also needs to be available to relocate the patient to the ED or appropriate in-patient facility.
Consistent physician staff in ambulatory facilities is uncommon. Physicians provide only a transient source of emergency medical care because they are often only present
when they have a specific clinic or procedure scheduled. Although the typical “knee- jerk” reaction might be to have them as the backbone of the response team, this may not always be the most prompt and efficient response. Patients often come to clinic early in the morning to register or stay later in the evening awaiting rides, picking up prescrip- tions, etc. It is highly unlikely that a physician would be available on site at these times to respond to a medical emergency. This inconsistent presence coupled with the fact that many staff physicians are not current on basic or ACLS practices makes them less than ideal candidates for a reliable first response to a CA in this setting. A physician-led first response would also require training and recurrent competency testing for all potential physician responders. Using physicians in this setting can be costly, constraining, and may potentially interfere with care of other patients of the physician is in the middle of a procedure, test, or consultation.
The nursing staff in most outpatient facilities has a much more consistent presence throughout the day. Most nurses are already trained in BLS, and many have undergone training with the AHA’s Healthcare Provider BLS course (BLS-D) that includes early defibrillation training with an AED. In many facilities, the nursing staff may provide an ideal first response for CA.
Many hospitals routinely have their in-patient code teams respond to episodes of cardiorespiratory arrest that occur in the outpatient areas. Response time intervals may be excessive given the travel distance required to reach many ambulatory care buildings.
If the in-patient team is used, full resuscitation equipment and immediate transportation to the ED or appropriate inpatient facility must be readily available to all outpatient areas.
In-hospital code teams are trained to respond to victims of cardiorespiratory arrest but are often not trained to respond to other medical emergencies, such as falls or injuries that require immobilization. Pulling the in-patient team to a remote outpatient building may significantly delay the response to a simultaneous inpatient arrest. Hospitals must critically evaluate their ambulatory care facility layout with specific attention to staffing and available resources and realize that a hospital-wide standard of care for responding to victims of CA consisting of BLS with early defibrillation followed by ALs may be achieved by very different mechanisms in in-patient vs outpatient areas. An example of how a large academic medical center with several on- and off-site ambulatory care areas chose to provide a prompt, consistent, and appropriate response to CA and other medical emergencies in their outpatient facilities was described by Peberdy et al. (19). The Virginia Commonwealth University Health System developed a Medical Emergency Response Team (MERT) to respond to medical emergencies in its outpatient areas. The team is designed as a two-tiered system. The first tier response is on-site BLS-D provided by a cohort of nurses working full time in the ambulatory care areas that underwent training in BLS, early defibrillation with AEDs, and first aid. Outpatient clinics and diagnostic areas are equipped with AEDs and a BLS bag containing barrier, noninvasive airway, and first aid equipment. The second tier of the response is provided by the local EMS system. The Richmond Ambulance Authority is an all ALS system with a median response time interval of 4.2 minutes to any location within the city. This is as fast or faster than it would take for the in-patient code team to respond. The paramedics provide adult and pediatric ALS, including all ALS equipment, and prompt transport to the ED.
They are capable of performing coordinated resuscitation efforts during the entire trans- port, very unlike most in-hospital transportation systems. The MERT system does not prohibit the participation of any on-site physician trained to respond to CA but is not dependent on it. A portable bag containing intravenous setups, airway equipment, and
resuscitation medications is available in each building if an on-site physician is ready to start ALS resuscitation efforts prior to arrival of the paramedics. A cost analysis done on the development and maintenance of this program over a 10-year period found that it added only an additional 5 cents per outpatient visit. This strategy is one example of how a hospital-affiliated ambulatory care system developed a fiscally responsible, prompt, and appropriate response for medical emergencies.
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