Evaluation of Detailed Cardiopulmonary Resuscitation Records in a Teaching Hospital
Sami A. Marzoogi, Yousef A. Khogheer and Abdullah M. Al-Fares
Saudi Medical Journal 1987; 8(5): 462-467
Department of Medicine, King Abdulaziz University Hospital. PO Box 6615, Jeddah 21452, Saudi Arabia
SAMI AHMAD MARZOOGI. Assistant Professor, Consultant Anaesthetist
YOUSEF AHMAD KHOGHEER, Assistant Professor. Consultant Physician
ABDULLAH MOHAMMED AL-FARES, Assistant Professor. Consultant Physician
Summary: In 1984 we conducted a prospective study aiming at the evaluation of the outcome of in-hospital cardiopulmonary resuscitation (CPR) performed at King Abdulaziz University Hospital in Jeddah. We subjected 142 resuscitated patients to detailed data recording such as causes of cardiac arrest (CA), arrival time of CPR team at the scene, number, type and frequency of administered drugs, number of DC shocks and frequency of intracardiac injections. During 1984, 198 CPR attempts were performed. Only three patients survived the resuscitative procedures to be discharged home. The overall survival rate was 2. Based on the analysis of our results, it seems that the availability of training programmes in CPR for residents, the proper organization of in-hospital CPR teams and the selection criteria of patients subjected to CPR are regarded as determinants of survival rate.
Introduction
Since the hospital opened in 1977 cardiopulmonary resuscitation (CPR) was performed on most of the in-patients and all Emergency Department admissions who had a cardiac arrest. However no detailed records of CPR attempts were available. The hospital has a capacity of 250 beds including all major specialities of clinical medicine, and an Emergency Department providing 24- hour medical services.
Cardiac arrest is a clinical term used to describe the state of a patient who is unconscious with no spontaneous respiration or palpable heart beats.
Eliastam1 reviewed the confusion concerning definition of cardiac arrest and survival rates of CPR. He argued that cardiac arrest results are often lumped under the title cardiac arrest without attention to aetiology, initial rhythm, rhythm at time of initiation of CPR or interval from collapse to definitive care. Moreover, the definition of successful resuscitation is not standardized. It includes for example, admission to hospital, return of palpable pulse and blood pressure for varying lengths of time, survival for one hour or alive at discharge from hospital.
The object of this study was to evaluate the in-hospital CPR procedures performed during the whole year of 1984, with the aim of identifying shortcomings and devising the best feasible solutions for the improvement of survival rates.
Materials and Methods
A cardiac arrest (CA) was announced by means of a paging system. A number of junior doctors including the On-Call Anaesthetist would rush to the scene and initiate CPR. There was no specific team assigned to do this job, nor did we have training facilities for medical and paramedical staff in basic and advanced CPR. The planning of this study took place during the last quarter of 1983. Detailed CPR data sheets were prepared and discussed with the nursing staff concerned. All participants were urged to exercise great care in the recording of data.
The study includes 142 resuscitated patients during the whole year of 1984. According to the following criteria 198 CPR records were evaluated:
(1) Age and sex of the patient
(2) Cause of cardiac arrest
(3) Response time of doctors (from paging of CA code until the arrival of medical
staff at the scene of CA)
(4) Number, frequency and route of administered drugs during CPR
(5) Number of defibrillations
(6) Duration of CPR attempts
(The difference between the number of patients and CPR records is explained by the fact that some patients were subjected to more than one CPR attempt.)
For the purpose of this study, cardiac arrest was defined as the sudden cessation of circulation and respiration resulting in documented loss of consciousness and requiring initiation of CPR.2 Successful CPR attempts are those where the patient survives for at least 24 hours with palpable pulse and recordable blood pressure with or without pressor agents. Survival rate is in the number of patients discharged from hospital after successful CPR. All patients arriving at the Emergency Department with CA were resuscitated regardless of the duration of the CA. The cohort of 142 patients consisted of 87 males and 55 females with an age ranging from birth to 81 years.
Cardiopulmonary resuscitation data were recorded on two separate sheets: the senior nurse, attending to the resuscitation completed one and the medical staff filled the other in. The nurses' sheet contained data related to nursing staff activities such as IV infusion, IV injections, and number of defibrillations, energy required and duration of CPR. The physicians' sheet comprised data such as causes of CA, relevant information of the patient's history, ECG changes complications of CPR.
. A summary of all data was prepared by the nursing administration for each month and put forward to the research team for evaluation. All hospital wards were provided with 'crash cart' containing standard equipment and drugs for CPR.
Results
Of the patients admitted to this study 50% were under 14 years of age and only 13% were over 60 years (Fig. 1). Non-cardiac causes of cardiac arrest were found in 67%, whereas cardiac causes amounted to 18% (Fig. 2). The breakdown of the figures of non-cardiac cause (95 cases) revealed:
27% prematurity and gross congenital abnormalities
19% malignant diseases
16% respiratory diseases
12% central nervous system diseases
8% septic shock
2% accidents (electricity, drowning).
The response time did not exceed 5 min in 88% of all CPR codes (Fig. 3). Only 10% of the CPR attempts were performed in the emergency department. Intracardiac injections were performed in 63% of the CPRs. The duration of CPR exceeded 15 min in 75% of CPR attempts. The most frequently used drugs were sodium bicarbonate and epinephrine (82% and 85% respectively). Defibrillation was carried out in 51 CPR attempts (26%), 14% required up to two DC shocks.
Discussion
The striking figure in this study was the survival rate to discharge of only three patients (2.1%), which was regarded as very disappointing compared with other studies. Sandoe3 compared the efficiency of in-hospital resuscitation i.e. survival rates defined as long-term survivals, divided by the total number of resuscitation attempts. He found a common trend of 3-13% in the emergency department, 5-20% in general wards and as high as 60% in patients with ventricular fibrillation. Basket et al.4 reported an overall survival rate of 19.6% in ventricular fibrillation due to myocardial infarction at 45.7%. Peatfield et al.5 found a survival rate to discharge of 8.7% of all patients over a 10-vear period excluding patients in coronary care and intensive care units. Only 2.1% of general ward patients survived to discharge and the yearly survival rate was 4-13.8%. The survival rate of ward patients is similar to our own overall survival rate. These three studies did not include the age group from birth to 14 years.
The low survival rate in the present study should be considered in relation to the cause of cardiac arrest, i.e. 67% were due to non-cardiac causes and only 18% were attributed to primary cardiac disease (Fig. 2). Thus, it is understandable that most of the CPR procedures performed were less likely to be successful as the selection criteria for resuscitable patients were poorly defined and subject to personal and ethical interpretations. During the whole year of 1984, 147 patients died in hospital, of which 142 patients (96.6%) were resuscitated, which means that almost all in-hospital CA patients were resuscitated regardless of their clinical state before cardiac arrest.
As stated by Sandoe3, uncritical resuscitation of patients in whom cardiac arrest developed as a logical endpoint of progressive deterioration in the clinical state is the explanation for the low survival rate in general ward resuscitation.
Fox and Lipton6 attempted to develop criteria to assist physicians in their decision whether or not to perform CPR. In spite of these criteria it is left to the physician at the scene to decide whether to perform or withhold resuscitative procedures. Messert and Quglieri7 pictured the profile of an ideal candidate for successful CPR. The patient would have an arrest in the CCU in mid-afternoon, would not have a multi-system disease (e.g. neurological disorder), and would have an easy and quickly reversible cardiac rhythm.
Another determinant of survival rate is the duration of CPR. Our study showed that 75% of CPR attempts lasted more than 15 min, 21% from 5-15 min, and only 1% for less than 5 min. In 3% of all CPR procedures the duration was not noted. We believe that most of our CPR attempts were doomed to produce a poor success rate as judged by the duration of CPR attempts, reported by Bedell2 who found a 95% mortality following all CPR attempts lasting more than 5 min.
The analysis of drugs administered during CPR revealed that two drugs were used most frequently, namely sodium bicarbonate and epinephrine, in 82% and 85% respectively of all CPR attempts. Other drugs, such as atropine and lignocaine were given in less than 20% of all CPR attempts. Calcium was used in 38% of all resuscitations and we found that no particular distinction was made as to the indication or sequencing of calcium therapy during attempted CPR. However, it is doubtful whether calcium administration affected our survival rate. The American Heart Association standards currently recommend calcium use after sodium bicarbonate and epinephrine in cases of electromechanical dissociation and in asystole.8 Contrary to these recommendations, other authors argue against the administration of calcium during resuscitation. Greenberg9 stated that, in addition to calcium being useless, it adversely affected post-resuscitation cerebral perfusion. Meuret et al.10 concluded that calcium should not be used in CPR and that epinephrine was still the drug of choice in resuscitation.
The response time was within 5 min in 88% of all our CPR attempts (Fig. 3). Bedell et al 2 reported a response time within 5 min in 89% of all attempted resuscitations. Defibrillation was carried out in 26% of all CPR attempts. It is however, doubtful whether the diagnosis of ventricular fibrillation was established before applying DC shock.
It was interesting to learn that intracardiac injection in this study was performed in almost two-thirds of the CPR procedures. We agree with other authors11 that such injection should be avoided in CPR because of inaccuracy in aiming at the cavity of the left ventricle and the inevitable interruption of extracardiac compressions. The latter outweighed the expected pharmacological effect of the drugs administered by intracardiac injections. Although the central venous route is preferable, the peripheral route can be accepted.12
Eisenberg13 divided the determinants of survival into two categories: fate factors and
program factors.
We believe this study has been useful in identifying shortcomings of program and fate factors, such as manual skills, organization of the CPR team and selection criteria of patients subjected to CPR. Although some program factors, such as: response time, and selection of drugs agreed with accepted standards, others showed some deficiencies, such as manual skills, (since junior house physicians were not trained in the skills of basic and advanced life support) the organization of the CPR team within the hospital, and strict adherence to selection criteria for resuscitable patients.
We admit that some of the data in this study were incomplete, and the number of patients was too small to allow detailed statistical evaluation such as multivariate analysis, as done by Bedell.2 The importance of program factors in determining the survival rate of in-hospital CPR has however been clearly demonstrated.
We would like to emphasize the following recommendations in order to improve survival rates of in-hospital resuscitation:
(1) Proper organization of the CPR team within the hospital with an instruction manual at hand.
(2) Improving resuscitative techniques by organizing CPR training programmes for all medical and paramedical staff.
(3) Critical selection of resuscitable patients according to underlying causes of cardiac arrest.
(4) Avoidance of intracardiac injections.
(5) Meticulous documentation of CPR data.
(6) Continual evaluation of CPR records with the objective of improving CPR efficiency.
(7) Critical selection of drugs to be used during CPR according to updated international standards, and avoidance of drugs with little or harmful effects.
Acknowledgements
The Authors wish to thank the Director of Nursing and her associates for extensive work in recording and retrieving the data and Miss Judi Grey for her excellent secretarial assistance in preparing this manuscript.
References
