Approach to CPR in hospitals must improve

A report produced by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has highlighted deficiencies in the care of patients whose condition deteriorated after arrival at hospital. Around one-third of in-hospital cardiac arrests and subsequent attempts to resuscitate could have been prevented if better assessment on hospital admission took place and recognition and response had occurred when acutely ill patients deteriorated, according to the report ‘Time to Intervene?’ The study aimed to identify variability and remediable factors in the process of care of adult patients receiving resuscitation in hospital, including factors which may affect the decision to initiate the resuscitation attempt, the outcome and the quality of care following the resuscitation attempt, and antecedents in the preceding 48 hours that may have offered opportunities for intervention to prevent cardiac arrest. The study included all adult patients who had a cardiac arrest, triggering either a call to the resuscitation team (or equivalent) via 2222 (or the completion of an audit form subsequent to the resuscitation attempt) that led to the delivery of chest compressions or defibrillation during a 14-day study period from 1-14 November 2010. The results have led to a call for improvements in recognition and response to patient deterioration, as well as decision-making around what care is likely to benefit acutely unwell patients, including ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions.

Warning signs not recognised

Commenting on the study findings, report author and NCEPOD lead clinical coordinator, Dr George Findlay said: “The recognition of acute illness, response to it and escalation of concerns to consultants when patients are deteriorating, is not happening consistently across hospitals.” Patient assessment on admission was found to be deficient in 47% of cases, and there were warning signs that the patient was deteriorating and might arrest in 75% of cases. However, the warning signs were not recognised in 35% of those patients, not acted on in 56% and not communicated to senior doctors in 55% of cases. NCEPOD advisors also identified a lack of input from senior clinicians in the 48-hours prior to cardiac arrest. “Senior doctors must be involved in the care planning process for acutely ill patients at an earlier stage, and support junior doctors to recognise the warning signs when a patient is deteriorating,” said Dr Findlay. “The lack of senior input fails patients by both missing the opportunity to halt deterioration and also by failing to question if CPR will actually improve outcome.” Many in-hospital cardiac arrests are predictable events not caused by primary cardiac disease.1 In this group, cardiac arrest often follows a period of slow and progressive physiological derangement that is often poorly recognised and treated.2 Identification of obvious markers of deterioration in patients who have a cardiac arrest was shown as far back as 1990 by Schein and colleagues3 and has been subsequently demonstrated in other publications.4-7 Following work by NCEPOD,1 the National Institute for Clinical Excellence (NICE) produced clinical guidance to promote recognition and management of the acutely unwell patient,8 based on the evidence of delayed recognition of illness and that intervention could improve outcomes and reduce cardiac arrest rates.9-12 It was hoped that the changes put in place as a result of this guidance would have improved processes of care for acutely ill patients and that this would be evident in patients who had a cardiac arrest. However, the report identified that a decision about whether resuscitation should or should not be attempted was documented on admission in only 10% of cases. NCEPOD advisors believe that in 174/230 cases where it was possible to make a judgement, the patient should have but did not have a DNACPR order. This would indicate that resuscitation is being wrongly attempted in many cases because nobody has recognised that a patient is in danger of a cardiac arrest and that CPR would be unlikely to be effective.