Inside Medicine: In-hospital cardiac arrest common – and a tangle
10/11/2012 12:00 AM
10/10/2012 1:10 PM
Despite our expectations that we go to the hospital to get well, each year more than 200,000 people have their heart stop unexpectedly – cardiac arrest – while in the hospital.
In most cases treatment involves cardiopulmonary resuscitation. How effective are hospitals at dealing with these emergencies? Based on our experience watching a cardiac arrest on TV, we might assume hospitals are nearly always successful at CPR.
Following most TV cardiac arrests the patient ends up doing just fine. In fact, only 14 percent of those who have a cardiac arrest in the hospital live to leave alive, and many of these will have some brain damage requiring nursing home placement.
Survival of an in-hospital cardiac arrest involves an entire system – doctors, nurses, respiratory therapists, pharmacists and aides all working together in a rapid, coordinated manner.
But even a rapid-response team does not guarantee success. An essential requirement is that the heart not be so badly damaged that it is incapable of being resuscitated. Still it turns out that some hospitals are much better than others at cardiac resuscitation – the time of day, the location where the cardiac arrest occurs, and the experience of the team all effect survival.
But what exactly do we mean when we say "successful resuscitation"? Some define success by when the heart starts to beat on its own. Others define success by whether the person survives 24 hours. Others reserve the term for those who leave the hospital alive – a definition that is much more meaningful to the patient and family than short-term measures based heart function and not the person.
The issue is more than just academic babble. Having a common definition allows us to compare hospitals with each other, which can in turn improve performance. Another issue that becomes important in looking at survival after cardiac arrest is the person's expressed wishes – what we call an advance directive.
If a hospital knows a person wishes to be resuscitated, it may be more aggressive than if a person's wishes are unknown – particularly if the person has a life-threatening condition such as cancer.
Advance directives are woefully underused and doctors infrequently take adequate time to discuss people's values and preferences. They rarely offer specifics such as the likely outcomes of CPR – for example, the chance of surviving to hospital discharge or the return of normal brain function.
It is surprising how little we know about cardiac arrests – whether it occurs in the hospital or in the community. Do hospitals with trainees – students and medical residents – do better or worse? Do hospitals with more or newer technology perform better?
It is time to invest some resources in answering these questions, then disseminating the findings so the quality of care will improve.
We know from many other medical examples that when people study something and publicly compare hospitals, outcomes improve.
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