Summary Background During in-hospital cardiac arrests, how long resuscitation attempts should be continued before termination of efforts is unknown. We investigated whether duration of resuscitation ...attempts varies between hospitals and whether patients at hospitals that attempt resuscitation for longer have higher survival rates than do those at hospitals with shorter durations of resuscitation efforts. Methods Between 2000 and 2008, we identified 64 339 patients with cardiac arrests at 435 US hospitals within the Get With The Guidelines—Resuscitation registry. For each hospital, we calculated the median duration of resuscitation before termination of efforts in non-survivors as a measure of the hospital's overall tendency for longer attempts. We used multilevel regression models to assess the association between the length of resuscitation attempts and risk-adjusted survival. Our primary endpoints were immediate survival with return of spontaneous circulation during cardiac arrest and survival to hospital discharge. Findings 31 198 of 64 339 (48·5%) patients achieved return of spontaneous circulation and 9912 (15·4%) survived to discharge. For patients achieving return of spontaneous circulation, the median duration of resuscitation was 12 min (IQR 6–21) compared with 20 min (14–30) for non-survivors. Compared with patients at hospitals in the quartile with the shortest median resuscitation attempts in non-survivors (16 min IQR 15–17), those at hospitals in the quartile with the longest attempts (25 min 25–28) had a higher likelihood of return of spontaneous circulation (adjusted risk ratio 1·12, 95% CI 1·06–1·18; p<0·0001) and survival to discharge (1·12, 1·02–1·23; 0·021). Interpretation Duration of resuscitation attempts varies between hospitals. Although we cannot define an optimum duration for resuscitation attempts on the basis of these observational data, our findings suggest that efforts to systematically increase the duration of resuscitation could improve survival in this high-risk population. Funding American Heart Association, Robert Wood Johnson Foundation Clinical Scholars Program, and the National Institutes of Health.
The goal of immediate post-cardiac arrest care is to optimize systemic perfusion, restore metabolic homeostasis, and support organ system function to increase the likelihood of intact neurological ...survival. The post-cardiac arrest period is often marked by hemodynamic instability as well as metabolic abnormalities. Support and treatment of acute myocardial dysfunction and acute myocardial ischemia can increase the probability of survival. Interventions to reduce secondary brain injury, such as therapeutic hypothermia, can improve survival and neurological recovery. Every organ system is at risk during this period, and patients are at risk of developing multiorgan dysfunction. The comprehensive treatment of diverse problems after cardiac arrest involves multidisciplinary aspects of critical care, cardiology, and neurology. For this reason, it is important to admit patients to appropriate critical-care units with a prospective plan of care to anticipate, monitor, and treat each of these diverse problems. It is also important to appreciate the relative strengths and weaknesses of different tools for estimating the prognosis of patients after cardiac arrest.
The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing ...may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.
Crisis-level overcrowding conditions in emergency departments (EDs) have led hospitals to seek out new patient-flow designs to improve both responsiveness and safety. One approach that has attracted ...attention and experimentation in the emergency medicine community is a system in which ED beds and care teams are segregated and patients are "streamed" based on predictions of whether they will be discharged or admitted to the hospital. In this paper, we use a combination of analytic and simulation models to determine whether such a streaming policy can improve ED performance, where it is most likely to be effective, and how it should be implemented for maximum performance. Our results suggest that the concept of streaming can indeed improve patient flow, but only in some situations. First, ED resources must be shared across streams rather than physically separated. This leads us to propose a new "virtual-streaming" patient flow design for EDs. Second, this type of streaming is most effective in EDs with (1) a high percentage of admitted patients, (2) longer care times for admitted patients than discharged patients, (3) a high day-to-day variation in the percentage of admitted patients, (4) long patient boarding times (e.g., caused by hospital "bed-block"), and (5) high average physician utilization. Finally, to take full advantage of streaming, physicians assigned to admit patients should prioritize upstream (new) patients, whereas physicians assigned to discharge patients should prioritize downstream (old) patients.
Good outcomes for in-hospital cardiac arrest (IHCA) depend on a skilled resuscitation team, prompt initiation of high-quality cardiopulmonary resuscitation and defibrillation, and organisational ...structures to support IHCA response. We examined the role of nurses in resuscitation, contrasting higher versus lower performing hospitals in IHCA survival.
We conducted a descriptive qualitative study at nine hospitals in the American Heart Association's Get With The Guidelines-Resuscitation registry, purposefully sampling hospitals that varied in geography, academic status, and risk-standardised IHCA survival. We conducted 158 semistructured interviews with nurses, physicians, respiratory therapists, pharmacists, quality improvement staff, and administrators. Qualitative thematic text analysis followed by type-building text analysis identified distinct nursing roles in IHCA care and support for roles.
Nurses played three major roles in IHCA response: bedside first responder, resuscitation team member, and clinical or administrative leader. We found distinctions between higher and lower performing hospitals in support for nurses. Higher performing hospitals emphasised training and competency of nurses at all levels; provided organisational flexibility and responsiveness with nursing roles; and empowered nurses to operate at a higher scope of clinical practice (eg, bedside defibrillation). Higher performing hospitals promoted nurses as leaders-administrators supporting nurses in resuscitation care at the institution, resuscitation team leaders during resuscitation and clinical champions for resuscitation care. Lower performing hospitals had more restrictive nurse roles with less emphasis on systematically identifying improvement needs.
Hospitals that excelled in IHCA survival emphasised mentoring and empowering front-line nurses and ensured clinical competency and adequate nursing training for IHCA care. Though not proof of causation, nurses appear to be critical to effective IHCA response, and how to support their role to optimise outcomes warrants further investigation.
Survival outcomes following in-hospital cardiac arrest vary significantly across hospitals. Research suggests clinician education and training may play a role. We sought to identify best practices ...related to the education and training of resuscitation teams.
We conducted a descriptive qualitative analysis of semistructured interview data obtained from in-depth site visits conducted from 2016 to 2017 at 9 diverse hospitals within the American Heart Association "Get With The Guidelines" registry, selected based on in-hospital cardiac arrest survival performance (5 top-, 1 middle-, 3 low-performing). We assessed coded data related to education and training including systems learning, informal feedback and debrief, and formal learning through advanced cardiopulmonary life support and mock codes. Thematic analysis was used to identify best practices.
In total, 129 interviews were conducted with a variety of hospital staff including nurses, chaplains, security guards, respiratory therapists, physicians, pharmacists, and administrators, yielding 78 hours and 29 minutes of interview time. Four themes related to training and education were identified: engagement, clear communication, consistency, and responsive leadership. Top-performing hospitals encouraged employee engagement with creative marketing of new programs and prioritizing hands-on learning over passive didactics. Clear communication was accomplished with debriefing, structured institutional review, and continual, frequent education for departments. Consistency was a cornerstone to culture change and was achieved with uniform policies for simulation practice as well as reinforced, routine practice (weekly, monthly, quarterly). Finally, top-performing hospitals had responsive leadership teams across multiple disciplines (nursing, respiratory therapy, pharmacy and medicine), who listened and adapted programs to fit the needs of their staff.
Among top-performing hospitals excelling in in-hospital cardiac arrest survival, we identified core elements for education and training of resuscitation teams. Developing tools to expand these areas for hospitals may improve in-hospital cardiac arrest outcomes.
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