Strategies to Improve Cardiac Arrest Survival A Time to Act (2015) / Chapter Skim
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5 In-Hospital Cardiac Arrest and Post-Arrest Care
5 In-Hospital Cardiac Arrest and Post-Arrest Care
Pages 243-314
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From page 243... ...
. Survivalto-discharge rates and the likelihood of good neurologic outcomes and functional status following cardiac arrest vary substantially between OHCA and IHCA.
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From page 244... ...
This section also identifies current best practices that have resulted in favorable clinical outcomes, taking into consideration the existing limitations in evidence within the post-arrest care field. Finally, the chapter ties together common themes across resuscitation care settings and proposes strategies aimed toward improving the quality of care for all cardiac arrest patients within hospitals across the nation.
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From page 245... ...
Additionally, providers and care teams across multiple settings need to communicate effectively and have access to complete clinical information to be able to make appropriate decisions regarding postarrest care for individual patients. Within hospitals, resuscitation teams initially evaluate and manage IHCA patients in various nonintensive care areas.
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From page 246... ...
NOTES: Post-arrest treatments can begin at any point in this pathway, once patients achieve return of spontaneous circulation following an out-of-hospital cardiac arrest (OHCA) or an in-hospital cardiac arrest (IHCA)
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Recent studies assessing trends in the Get With The Guidelines-Resuscitation (GWTG-R) registry database have found improvements in patient outcomes; the rates of clinically significant neurologic disability (defined as a Cerebral Performance Category [CPC]
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From page 248... ...
It then reviews the current state of evidence regarding hospitals' approaches to managing and treating IHCA, and describes recent shifts in evidence related to teamwork and leadership efforts on resuscitation teams, along with advances in quality improvement tools and technology. Epidemiology Although the basic cardiac arrest rhythms and pathophysiology are similar for OHCA and IHCA, their underlying causes can be markedly different.
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From page 249... ...
PEA = pulseless electrical activity; pVT = pulseless ventricular tachycardia; VF = ventricular fibrillation. SOURCES: Chan, 2015; Daya et al., 2015 Finally, the types of treatments available to OHCA and IHCA patients are similar, but they have been variably studied across the conditions (e.g., therapeutic hypothermia)
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From page 250... ...
As discussed in Chapter 2, several studies of IHCA have noted disparate outcomes among African American and Hispanic populations, compared to that for white patients. According to the committee's commissioned analysis of GWTG-R data, African American patients were significantly less likely to survive to hospital discharge than were white patients following an IHCA (20.8 percent survival compared to 25.9 percent, respectively)
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From page 251... ...
However, because code teams are not always activated in critical care areas such as EDs, ICUs, or the operating room, counting these activations as a proxy for cardiac arrest can underestimate IHCA incidence (Morrison et al., 2013)
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From page 252... ...
A recent consensus document by the American Heart Association's (AHA's) recommended definition of IHCA incidence in admitted patients proposes a numerator that includes all patients who receive chest compressions and/or defibrillation, while the denominator reflects the total number of patients admitted to the hospital, including those in the ICUs and the operating and procedure rooms, along with their recovery areas (Morrison et al., 2013)
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From page 253... ...
As with incidence of IHCA, patient DNAR status and eligibility for resuscitation care affect the measurement of outcomes. The types of patients who undergo CPR and resuscitation care for IHCA may vary across hospitals and may significantly influence risk-adjusted survival rates across hospitals.
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From page 254... ...
With the exception of patients in CCUs, ICUs, and EDs, designated resuscitation teams are generally alerted to respond to an IHCA occurring anywhere within the hospital using a facility-wide activation system. Typically, team members provide immediate basic and advanced life support (CPR and defibrillation)
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From page 255... ...
. They are separate and distinct from traditional resuscitation teams which typically respond upon IHCA recognition (AHRQ, 2014a; Thomas et al., 2007b)
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From page 256... ...
. One literature review identified common behaviors and attributes of existing resuscitation teams, such as mutual trust and respect among team members, adaptive leadership, open communication, and a shared conception among team members of the purpose of the team and their individual roles (Manser, 2009)
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From page 257... ...
• Should have the ability to provide clinical as sessment, intervene to secure airway, provide cardiovascular support, administer appropriate ACLS medication, use ACLS cards and other cognitive aids, and troubleshoot defibrillators and other devices. resuscitation teams because of data demonstrating an association with improved outcomes, with these skills (Bhanji et al., 2010; Hunziker et al., 2011)
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From page 258... ...
. Ideally, facilities that have medical training programs should require that physicians in training be backed up by at least one attending physician whose specialty is hospital medicine, intensive care medicine, cardiovascular medicine, or emergency medicine.
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From page 259... ...
Cardiac arrest investigators have also explored different methods for detecting deterioration prior to an IHCA using physiological data. Early recognition would allow for an escalation of care (e.g., transfer to ICU for patients on the general medical floor)
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Box 5-2 presents the current gaps in evidence and points to future research needs. POST-ARREST CARE Post–cardiac arrest syndrome is a complex clinical condition with four primary pathophysiological consequences, which can include any combination of myocardial dysfunction, neurologic injury, systemic BOX 5-2 Priority Areas for Research in In-Hospital Care • Transition of care: Research needed to understand how to best optimize care transitions for cardiac arrest patients at admission, at discharge, and within hospitals, including key elements of the cardiac arrest that should be passed on to subsequent providers • Hospital resuscitation team structure and skill composition: More research is needed to standardize team composition and technical and nontechnical skillsets and to evaluate the effec tiveness of resuscitation teams in improving patient outcomes • Early detection of IHCA: Research is needed to improve early warning scores and telemetry to improve use of METs teams • Standardize quality metrics for IHCA: Define and select ap propriate IHCA process and performance metrics • Long-term outcomes of IHCA: Quality-of-life assessments, and patient utilization of health care resources after hospital dis charge, should be evaluated • Advanced directives, DNAR, and care termination: There is a need to understand how to best standardize and implement care decisions around advanced directives, DNAR and care termina tion, including education of patients and families • Disparities in IHCA: Better data on race and ethnicity and soci oeconomic factors are needed to identify high-risk populations and evaluate disparities in care and access to care
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From page 261... ...
Post–cardiac arrest cardiovascular injury also affects patient outcomes; approximately 30 percent of all deaths among cardiac arrest patients who were initially resuscitated were caused by reduced blood flow. However, multiple studies based on swine models suggest that permanent damage to the left ventricle can be avoided in the immediate period following resuscitation (Kern et al., 1997a,b; Neumar et al., 2008)
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From page 262... ...
There are additional gaps in evidence regarding long-term outcomes following post-arrest care. As a result of these limitations, the scientific evidence to support the therapies and care strategies offered for patients with post–cardiac arrest syndrome is less robust than that for the patients with other cardiovascular conditions such as acute myocardial infarction, often the precursor to cardiac arrest.
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From page 263... ...
. TTM, also known as ther apeutic hypothermia, is an early post-arrest intervention designed to re duce the body temperature in resuscitated, comatose cardiac arrest patients.
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From page 264... ...
In order to better evalu ate the effectiveness of PCI as an intervention for cardiac arrest, en courage its use in these critical patients, and not distort the statistics of facilities that offer these high-risk services, mortality and morbidity la boratory statistics for the post–cardiac arrest patients should be report ed separately from the general cardiac catheterization outcomes data. Some studies have found that providers are often reluctant to provide PCI for eligible patients because of concerns regarding public reporting of negative outcomes (Peberdy et al., 2013)
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From page 265... ...
. One IHCA study found that longer dosing intervals in both shockable and nonshockable rhythms was associated with greater survival rates following cardiac arrest (Warren et al., 2014)
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Glucose control has been an area of considerable controversy, however, be cause even though it has been shown to be beneficial in select critical care situations (e.g., sepsis) , it has not been uniformly applied to cardiac arrest patients.
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. Because of the pathophysiological similarities between sepsis and post– cardiac arrest syndrome, EGDT has been adapted for post-arrest care to provide hemodynamic and oxygenation monitoring, in combination with intravenous medication (Nichol et al., 2010)
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From page 268... ...
. As a majority of IHCAs now occur in ICUs, where such monitoring is often already in place, the transition to resuscitation protocols that monitor and adapt to patient vital signs will potentially benefit a large proportion of cardiac arrest patients (Berg et al., 2013; Girotra et al., 2012; Sutton et al., 2014a)
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From page 269... ...
. In post-arrest care, MRI-based imaging techniques provide sensitive and accurate methods of detecting brain lesions and other neurologic features that strongly correlate with poor neurologic outcomes (Choi et al., 2010; Galanaud and Puybasset, 2010; Wijman et al., 2009; Wu et al., 2009)
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From page 270... ...
. Although there is limited research devoted to cardiac arrest care for racial and ethnic minority patients, available evidence indicates disparities in both access to care and outcomes.
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The most commonly used score is the Pediatric Cerebral Performance Score, which also has significant shortcomings in differentiating mild from moderate disability and was designed to assess neurologic function after pediatric intensive care -- not in-hospital cardiac arrest (Fiser et al., 2000)
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From page 272... ...
Neurologic assessment scores have been developed in order to provide insights into short and long-term neurologic outcomes. There are multiple scoring systems, including the following: • The Cerebral Performance Category (CPCa)
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. • The Cardiac Arrest Survival Post-Resuscitation In-hospital (CASPRI)
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Appropriate Timing of Prognosis Post-arrest patients often require sequential and frequent neurologic evaluations in the ICU. Determination of neurologic prognosis can be
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From page 275... ...
Although neurologic prognostic assessments can provide reasonable accuracy regarding the likelihood of meaningful recovery, there are no clear guidelines beyond maintaining a 72 hours or longer observation period, with respect to termination of care for cardiac arrest patients. Albaeni and colleagues found that post-arrest care is withdrawn early (within 48 hours of hospital admission)
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From page 276... ...
Variability in Post–Cardiac Arrest Care The literature reports remarkable variation in survival-to-discharge rates that range from 2 to 41.5 percent among all cardiac arrest patients with varying degrees of post–cardiac arrest syndrome (Go et al., 2014; Nadkarni et al., 2006; Sirbaugh et al., 1999)
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From page 277... ...
Cardiac Arrest Centers of Excellence Because care for the post-arrest patient is complex and often requires multidisciplinary team approaches, some regions in the United States (Arizona, Minnesota, New York, Ohio, Texas, and Virginia) have developed regional systems-of-care to improve OHCA resuscitation care and patient outcomes (Nichol et al., 2010)
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From page 278... ...
and therapeutic capabilities (e.g., TTM, PCI, dialysis) to be able to provide a bundle of essential treatments that have demonstrated benefit in treating post-arrest care syndrome and improving patient outcomes.
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NOTES: CCU = critical care unit; ED = emergency department; ICU = intensive care unit; NICU = neonatal intensive care unit; PCI = percutaneous coronary intervention; ROSC = return of spontaneous circulation. SOURCE: Myerburg, 2014.
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From page 280... ...
In spite of these challenges and existing knowledge gaps, health care systems and academic medical centers that practice aggressive, multidisciplinary post-resuscitation care often report excellent patient outcomes, with upward of 80 percent of survivors having favorable neurologic outcomes at discharge (Langhelle et al., 2003; Nolan et al., 2010)
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From page 281... ...
Multiple guidelines on IHCA and post-arrest care treatment protocols exist; however, the scientific evidence base demonstrating the effectiveness of specific protocols and guidelines are limited or, at best, mixed. Relatively few hospitals regularly monitor cardiac arrest outcomes, and there are currently few national standards that require performance benchmarking.
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From page 282... ...
Additionally, IHCAs are less likely to occur as a result of preexisting cardiovascular disease and, notwithstanding substantial variations in the quality of care, IHCA patients are more likely to receive early treatment. Hospital systems can benefit from separate administrative billing codes for OHCA and IHCA, because the cost of inpatient care for IHCA patients and OHCA-patients who receive hospital-based post-arrest care are markedly different.
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From page 283... ...
This affects efforts to measure and improve the quality of cardiac arrest care provided by hospital personnel,
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CPR Quality Improvement: Devices, Debriefing, and Simulation Training Many different strategies have been applied in efforts to improve the quality of resuscitation care for IHCA. CPR feedback devices provide one technology-driven opportunity to improve resuscitation care.
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From page 285... ...
. In a large tertiary care children's hospital, implementation of formalized debriefing after cardiac arrest was associated with improved survival to hospital discharge and improved survival with favorable neurologic outcome (Wolfe et al., 2014)
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From page 286... ...
or post-arrest care teams can enhance and streamline the quality of resuscitation care within hospitals. In their respective guidelines and statements, the ILCOR, the European Resuscitation Council, and the AHA have recognized the importance of teamwork, communication and leadership to the performance of resuscitation teams, and the effectiveness of targeted training to develop these vital behaviors (Bhanji et al., 2010; Mancini et al., 2010; Nolan et al., 2010)
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From page 287... ...
Simulation training for cardiac arrest resuscitation teams, described in the previous section, is one method of developing necessary technical and nontechnical skills. Crew resource management (also known as crisis resource management)
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From page 288... ...
There are general Joint Commission standards related to resuscitation services in hospitals for quality improvement review, evaluation, and action that apply to resuscitation care; however, none are specifically designed for inhospital cardiac arrest (see Box 5-7 for a summary of relevant standards)
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SOURCE: The Joint Commission, 2007. capture outcomes longitudinally across the continuum of care or include assessments of care related to the post–cardiac arrest state.
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IHCA incidence rate in noncritical care, nonprocedural, inpatient areas per 1,000 patientdays, (3) proportion of hospitals (with more than 200 beds)
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From page 291... ...
. Developing and formally endorsing standard performance metrics for cardiac arrest could improve resuscitation care processes, enhance patient outcomes, and support future research efforts to optimize care for IHCA, OHCA, and post-arrest care.
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From page 292... ...
. Finally, it appears that CQI efforts for resuscitation care need to focus directly on the unique aspects of inhospital cardiac arrests or post-arrest care, because it is unlikely that spillover effects will occur from similar efforts related to other disease processes.
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. Because withholding resuscitation care requires an order that establishes DNAR status, hospitals should have a standard protocol for discussing advance directives with patients, emphasizing patient autonomy and informed decision making.
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From page 294... ...
o More research targeting simulation training, debriefing strate gies, and mechanical devices can improve quality of CPR and resuscitation care. o Team training is needed to improve IHCA and post-arrest care response.
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From page 295... ...
These differences occur partially because of a lack of scientific evidence and known standards in resuscitation care. In response to the growing literature that highlights these systemic failures, experts in the resuscitation field, guideline-setting organizations, and some hospital administrators are placing an increased emphasis on developing quality improvement strategies.
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Pediatric Critical Care Medicine 14(6)
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From page 297... ...
Pediatric Critical Care Medicine 8(3) :236-246; quiz 247.
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From page 298... ...
2006. Systematic review of randomized controlled trials of therapeutic hypothermia as a neuroprotectant in post cardiac arrest patients.
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From page 299... ...
Critical Care Medicine 40(10)
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From page 300... ...
Critical Care Medicine 35(3)
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From page 301... ...
Critical Care 14(2)
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Critical Care Medicine 35(7)
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Classic CQI integrated with comprehensive disease management as a model for performance improvement. Joint Commission Journal on Quality Improvement 25(8)
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From page 304... ...
2010a. Part 14: Pediatric advanced life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
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Critical Care Medicine 38:101-108. Meaney, P
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From page 306... ...
2010. Part 3: Ethics: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
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From page 307... ...
A scientific statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation 79(3)
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From page 308... ...
; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation 116(21)
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Critical Care Medicine 35(5)
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Critical Care Medicine 38(9)
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2009. Pro/con debate: Do the benefits of regionalized critical care delivery outweigh the risks of interfacility patient transport?
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Pediatric Critical Care Medicine 10(3)
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Pediatric Critical Care Medicine 15(9)
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Critical Care Medicine 43(3)
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