In-hospital Organization and Outcome of Cardiopulmonary Resuscitation in Finland with Special Reference to Utstein and Resuscitation 2000 Guidelines

................................................................................................................................................................................................ 6 LIST OF ORIGINAL PUBLICATIONS ..................................................................................................................................................... 7 ABBREVIATIONS AND DEFINITIONS ................................................................................................................................................... 8 INTRODUCTION ........................................................................................................................................................................................ 9 REVIEW OF THE LITERATURE .......................................................................................................................................................... 10 In-hospital cardiopulmonary resuscitation – Historical background ................................................................... 10 Studies on in-hospital CPR Variation in survival...................................................................................................... 10 The in-hospital Utstein Guidelines – A consensus concerning resuscitation definitions and documentation ................................................................................................................. 12 Studies performed according to the Utstein style ........................................................................................................ 12 Recent studies on in-hospital resuscitation ................................................................................................................... 12 In-hospital resuscitation management – The importance of organization ......................................................... 13 Hospital and patient characteristics predicting survival after in-hospital CPR – When and where to start, not to start, and when to stop? .................................................. 14 Post-resuscitation care ............................................................................................................................................................ 15 Do not resuscitate orders and living wills – Issues of ethics.................................................................................... 16 Future perspectives – From treatment to prevention?............................................................................................... 16 Use of amiodarone in shock-resistant VF and pulseless VT .................................................................................... 17 AIM OF THE STUDY ............................................................................................................................................................................. 18 MATERIALS AND METHODS .............................................................................................................................................................. 19 Study setting and design ........................................................................................................................................................ 19 Data collection............................................................................................................................................................................. 20 CPR management in Finnish hospitals (I) .............................................................................................................. 20 Evaluation of in-hospital Utstein style guidelines (II) ...................................................................................... 20 Implementation of DNAR orders in four Finnish secondary hospitals (III)............................................... 22 Use of undiluted amiodarone in OHCA (IV) ........................................................................................................ 22 Impact of hospital care on survival after OHCA (V)............................................................................................ 23 Statistical methods ................................................................................................................................................................... 23 RESULTS................................................................................................................................................................................................. 24 In-hospital resuscitation management and training (I)............................................................................................. 24 Training in CPR ................................................................................................................................................................. 24 CA recognition and alarm systems ............................................................................................................................. 24 Defibrillators and defibrillation .................................................................................................................................. 24 Advanced life support and resuscitation teams ..................................................................................................... 24 Guidelines, data collection, time intervals, and measurement of improvement ...................................... 25 DNAR orders ...................................................................................................................................................................... 25 CPR in four secondary hospitals according to Utstein Guidelines (II-III).......................................................... 25 Collection of the Utstein parameters ........................................................................................................................ 25 CA variables ......................................................................................................................................................................... 26 Treatment variables ......................................................................................................................................................... 26 Outcome variables ............................................................................................................................................................. 26 Factors associated with survival ................................................................................................................................ 27 Prevalence of DNAR orders and advance directives in four Finnish secondary hospitals (III) ................ 28 DNAR orders........................................................................................................................................................................ 28 Living wills ........................................................................................................................................................................... 29 Patients with CA without a DNAR order ................................................................................................................ 29 Unwitnessed CA on the wards...................................................................................................................................... 29 Impact of antiarrhythmic treatment with undiluted amiodarone and of hospital care on outcome after OHCA (IV-V) ................................................................................................................. 29 Characteristics of patients receiving amiodarone................................................................................................. 29 Hypotension and bradycardia after ROSC in patients found in VF/VT ..................................................... 29 Patients with PEA or asystole as the initial rhythm........................................................................................... 30 Outcome of patients admitted to hospital after OHCA ...................................................................................... 30 Factors independently predictive of outcome with multiple logistic regression....................................... 31 Template presentation............................................................................................................................................................. 32 DISCUSSION........................................................................................................................................................................................... 34 Resuscitation selection and outcome ................................................................................................................................. 34 Survival.................................................................................................................................................................................. 34 Variation in CA variables and survival among the study hospitals.............................................................. 34 The influence of initial rhythms on survival after IHCA ......................................................................................... 34 Initial rhythm VF/VT ....................................................................................................................................................... 34 Initial rhythm PEA or asystole .................................................................................................................................... 35 In-hospital resuscitation management ............................................................................................................................. 35 Training in BLS and ALS ............................................................................................................................................... 35 Defibrillation........................................................................................................................................................................ 36 AEDs in the in-hospital setting.................................................................................................................................... 37 Resuscitation management............................................................................................................................................ 37 In-hospital Utstein Guidelines ............................................................................................................................................ 38 Patients suffering unwitnessed CA on the wards ....................................................................................................... 38 DNAR orders and living wills ............................................................................................................................................... 38 DNAR policies and prevalence of DNAR orders .................................................................................................... 38 Factors associated with the presence of DNAR orders ....................................................................................... 39 Documentation of DNAR orders .................................................................................................................................. 39 Patient autonomy ............................................................................................................................................................. 39 Living wills ........................................................................................................................................................................... 40 Limited resuscitation ....................................................................................................................................................... 40 Use of undiluted amiodarone in OHCA management ................................................................................................ 40 Haemodynamic considerations concerning undiluted amiodarone................................................................ 40 The use of undiluted amiodarone ................................................................................................................................ 41 Outcome of patients with OHCA ................................................................................................................................. 41 The impact of post-resuscitation care on survival after OHCA .............................................................................. 41 Overall survival rates and pre-hospital factors predictive of survival ......................................................... 41 Blood glucose and mortality .......................................................................................................................................... 42 Use of beta-blocking agents and survival................................................................................................................. 42 Potassium levels and survival ...................................................................................................................................... 43 Non-significant factors..................................................................................................................................................... 43 Quality of post-resuscitation care .............................................................................................................................. 43 LIMITATIONS OF THE STUDY............................................................................................................................................................ 44 Subjectivity................................................................................................................................................................................... 44 Time intervals ............................................................................................................................................................................. 44 DNAR orders ............................................................................................................................................................................... 44 Difficulties typical for retrospective studies .................................................................................................................. 44 The impact of clinical interventions ................................................................................................................................... 44 SUMMARY AND CONCLUSIONS ......................................................................................................................................................... 45 FUTURE IMPLICATIONS ...................................................................................................................................................................... 46 Cost-effectiveness of current resuscitation strategies ................................................................................................ 46 Prevention .................................................................................................................................................................................... 46 Resuscitation management ................................................................................................................................................... 46 Medical futility ........................................................................................................................................................................... 46 Post-resuscitation and secondary prevention strategies ........................................................................................... 46 Documentation and audit ....................................................................................................................................................... 47 SAMMANDRAG (SWEDISH SUMMARY)............................................................................................................................................ 48 YHTEENVETO (FINNISH SUMMARY) .............................................................................................................................................. 50 ACKNOWLEDGEMENTS ....................................................................................................................................................................... 51 REFERENCES......................................................................................................................................................................................... 53 ERRATA................................................................................................................................................................................................... 60 ORIGINAL PUBLICATIONS .................................................................................................................................................................. 61 kirja.indd 4-5 23.3.2004, 8:19:14 6 – M A R K U S S K R I F V A R S – C A R D I O P U L M O N A R Y R E S U S C I T A T I O N I N F I N L A N D C A R D I O P U L M O N A R Y R E S U S C I T A T I O N I N F I N L A N D – M A R K U S S K R I F V A R S – 7 Aim: To study resuscitation and post-resuscitation care strategies, including outcomes, and factors contributing to outcome, in and outside the hospital in Finland with reference to the Utstein Guidelines, for uniform data collection from 1997 and to the current international Resuscitation Guidelines from 2000. Materials and methods: In-hospital resuscitation strategies in Finland were assessed using a cross-sectional mail survey, and by prospectively collecting cardiac arrest (CA) management data as recommended and defined by the Utstein Guidelines, in four secondary hospitals during one year (Studies I-III). The management of patients with out-of-hospital CA (OHCA), emphasizing use of undiluted amiodarone and subsequent hospital care, was evaluated retrospectively by analysis of data from the ambulance ́ and hospital charts (Studies IV-V). Results: A majority of Finnish hospitals had an appointed physician or nurse in charge of in-hospital cardiopulmonary resuscitation (CPR) activities. Despite this most hospitals stated that the in-hospital training activities were insufficient. Few hospitals had strategies for early defibrillation outside the cardiac care units (CCU) and intensive care units (ICU). The short-term outcome rates of in-hospital CPR in four Finnish secondary hospitals were similar, and the long term outcome rates were lower, than rates previously reported. The only factor shown to be associated with survival was the delay to defibrillation in patients with an initial rhythm of either ventricular fibrillation (VF) or ventricular tachycardia (VT). Most patients who had a CA, from whom CPR was withheld, had, prior to the arrest, a valid “do not resuscitate” (DNR) order in place nowadays often called “do not attempt to resuscitate” (DNAR) but it was not uniformly documented in the patient charts. Variations in the prevalence of DNAR orders among those patients that were not resuscitated were evident between and within hospitals. Blood pressure levels after return of spontaneous circulation (ROSC) were similar among patients who did or did not receive amiodarone as an undiluted bolus; patients with asystole or pulseless electrical activity as the initial rhythm did not survive to hospital discharge. For patients admitted alive after OHCA, age, delay before ROSC, mean 72-hour blood glucose and plasma (or serum) potassium levels, and use of beta-blocking agents during postresuscitation care independently predicted survival at six months after the event. Conclusions: Given the recommendations of the current Resuscitation Guidelines, this study suggests that in-hospital CA management strategies in Finland would need improvement. This situation is probably not unique to Finland. The Utstein Guidelines were found to be a useful but laborious tool collection of data on in-hospital CAs. The low rate of long-term survival (9%) after CA may in part be due to factors not open to organizational intervention. In any case and based on the results, it seems logical to shorten the delay to defibrillation in patients with VF/VT as the initial rhythm, especially in CA occurring outside the CCU and the ICU. The application of DNARs was common, but lack of recommendations on uniformity probably contributed to the inconsistencies in charting. Amiodarone can be administered undiluted for treatment of arrhythmias in resuscitation, which simplifies the OHCA treatment protocol. Based on the present records, its impact, if any, on the outcome of patients with OHCA, with initial rhythms other than VF/VT, remains open. Several in-hospital factors (e.g., blood glucose, blood potassium and use of beta-blocking agents during post-resuscitation care) independently predicted survival after OHCA. Bringing some of these factors closer to standard values might benefit these patients. This thesis is based on the following original publications, which will be referred to in the text by their Roman numerals I to V. I Skrifvars MB, Castrén M, Kurola J, Rosenberg PH. In-hospital cardiopulmonary resuscitation management: organization, management and training in hospitals of different levels of care. Acta Anaesthesiol Scand 2002;46:458-63 II Skrifvars MB, Rosenberg PH, Finne P, Halonen S, Hautamäki R, Kuosa R, Niemelä H, Castrén M. Evaluation of the in-hospital Utstein template in cardiopulmonary resuscitation in secondary hospitals. Resuscitation 2003;56:275-82. III Skrifvars MB, Hilden HM, Finne P, Rosenberg PH, Castren M. Prevalence of “do not attempt resuscitation” orders and living wills among patients suffering CA in four secondary hospitals. Resuscitation 2003;58:65-71. IV Skrifvars MB, Kuisma M, Boyd J, Repo J, Määttä T, Rosenberg PH, Castrén M. The use of undiluted amiodarone in the management of OHCA. Acta Anaesthesiol Scand 2004 (in press). V Skrifvars MB, Pettilä V, Rosenberg PH, Castren M. A multiple logistic regression analysis of in-hospital factors related to survival at six months in patients resuscitated from out-of-hospital ventricular fibrillation. Resuscitation 2003;59:319-28. The articles are reprinted with the kind permission of the copyright holders. – ABSTRACT – – LIST OF ORIGINAL PUBLICATIONS – kirja.indd 6-7 23.3.2004, 8:19:15 8 – M A R K U S S K R I F V A R S – C A R D I O P U L M O N A R Y R E S U S C I T A T I O N I N F I N L A N D C A R D I O P U L M O N A R Y R E S U S C I T A T I O N I N F I N L A N D – M A R K U S S K R I F V A R S – 9 AED Automated external defibrillator ACLS Advanced cardiac life support AHA American Heart Association ALS Advanced life support BLS Basic life support CA Cardiac arrest CABG Coronary artery bypass grafting CCU Cardiac care unit CPC Cerebral performance category CPP Coronary perfusion pressure CPR Cardiopulmonary resuscitation DAP Diastolic arterial blood pressure DNAR Do not attempt to resuscitate DNR Do not resuscitate EK-CH Etelä-Karjala Central Hospital EMS Emergency medical service ER Emergency room ERC European Resuscitation Council GW General ward HIE Hypoxic-ischaemicencephalopathy ICU Intensive care unit IHCA In-hospital cardiac arrest ILCOR International Liaison Committee on Resuscitation IQR Interquartile range J-CH Jyväskylä Central Hospital MAP Mean arterial blood pressure MET Medical emergeny team MI Myocardial infarction The treatment of cardiac arrest (CA) with cardiopulmonary resuscitation (CPR), including mouth-to-mouth ventilation and external chest compression, today widely known as basic life support (BLS), was described in the 1950s [3-5]. In the 1960s, the treatment concept was enhanced by external electric defibrillation [6-8], and the use of various drugs [9,10]: the entity called advanced life support (ALS) evolved. Extensive epidemiological and clinical research has identified several factors associated with increased as well as decreased survival from CA. The “chain of survival” [11], outlined during the early 1990s, summarizes the most important factors. At first, CPR was practiced only in hospitals. However, through a great amount of work, with the organization of prehospital emergency medical services (EMS), the outcomes and survival rates of patients with CA outside the hospital, have improved. It is doubtful whether a similar degree of improvement has occurred in the outcome of patients experiencing in-hospital cardiac arrest (IHCA). Survival rates for in-hospital CPR have remained fairly constant, in the range of 10 to 15%, but at the same time, the total number of CPR attempts has increased [12], meaning probably on sicker patients. The variety of in-hospital resuscitation strategies does not, however, seem to have changed much since the early 1970s. Resuscitation research, both in and outside the hospital, has been rendered difficult by inconsistencies both in data collection and – ABBREVIATIONS AND DEFINITIONS – NS Not statistically significant OHCA Out-of-hospital cardiac arrest OPC Overall performance category OA Operating area PCI Percutaneous coronary intervention PEA Pulseless electrical activity PH-CH Päijät-Häme Central Hospital PSDA Patient Self-Determination Act ROSC Return of spontaneous circulation SAP Systolic arterial blood pressure V-CH Vaasa Central Hospital VF Ventricular fibrillation VT Ventricular tachycardia The Utstein Guidelines for reporting outcomes of in-hospital cardiac arrests: Reporting guidelines published as a result of a consensus conference held at the Utstein Abbey, Stavanger, Norway, in the year 1996 and published in the year 1997 [1] Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: The first international resuscitation guidelines published jointly by the AHA and the ERC in the year 2000 [2] – INTRODUCTION – in reporting. Acknowledging this important problem, a consensus conference produced the Utstein style guidelines for out-ofhospital cardiac arrest (OHCA) in 1991 [13] and for IHCA in 1997 [1]. Thus far, the Utstein Guidelines have been very useful, although with certain limitations [14,15]. IHCA and resuscitation can be considered a complex medical problem which also involves medico-ethical issues. Research on in-hospital resuscitation is complicated by several confounding variables, and its true efficacy is yet to be determined. In addition, several other aspects of in-hospital cardiopulmonary resuscitation and of CA in general require supplementary research, such as the impact of in-hospital care after OHCA and the use of “do not resuscitate” (DNR) orders for patients from whom resuscitation should be withheld. In the year 2000, the new international Resuscitation Guidelines were published [2]. These new guidelines replace lidocaine with amiodarone as the antiarrhythmic drug of choice in the treatment of shock-resistant ventricular fibrillation. Amiodarone is not, however, due to its difficulty of administration, a drug that is optimal for OHCA management. The purpose of this thesis was to study different aspects of current CA management in Finland, in and outside the hospital, using definitions provided in the Utstein Guidelines for resuscitation research. In addition, this study examines the feasibility of using intravenous amiodarone, undiluted, a step saving time in OHCA management. kirja.indd 8-9 23.3.2004, 8:19:15 1 0 – M A R K U S S K R I F V A R S – C A R D I O P U L M O N A R Y R E S U S C I T A T I O N I N F I N L A N D C A R D I O P U L M O N A R Y R E S U S C I T A T I O N I N F I N L A N D – M A R K U S S K R I F V A R S – 1 1 – R E V I E W O F T H E L I T E R A T U R E – IN-HOSPITAL CARDIOPULMONARY RESUSCITATION – HISTORICAL