Resuscitation 92 (2015) 59–62

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Commentary and concepts

Education for cardiac arrest – Treatment or prevention?夽 Gary B. Smith a,∗ , John Welch b,c , Michael A. DeVita d , Ken M. Hillman e , Daryl Jones f,g,h a

Centre of Postgraduate Medical Research & Education, Bournemouth University, Bournemouth, UK Critical Care & Critical Care Outreach, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK c University College London Partners, London, UK d Critical Care, Harlem Hospital, New York, NY 10037, USA e University of New South Wales, Sydney, NSW 2052, Australia f University of Melbourne, Melbourne, VIC 3010, Australia g Monash University, Melbourne, VIC 3004, Australia h Intensive Care Specialist, Austin Hospital, Melbourne, VIC 3084, Australia b

a r t i c l e

i n f o

Article history: Received 17 February 2015 Received in revised form 1 April 2015 Accepted 17 April 2015 Keywords: Cardiac arrest Education Prevention Deterioration Advanced life support

a b s t r a c t In-hospital cardiac arrests (IHCA) occur infrequently and individual staff members working on general wards may only rarely encounter one. Mortality following IHCA is high and the evidence for the benefits of many advanced life support (ALS) interventions is scarce. Nevertheless, regular, often frequent, ALS training is mandatory for many hospital medical staff and nurses. The incidence of pre-cardiac arrest deterioration is much higher than that of cardiac arrests, and there is evidence that intervention prior to cardiac arrest can reduce the incidence of IHCA. This article discusses a proposal to reduce the emphasis on widespread ALS training and to increase education in the recognition and response to pre-arrest clinical deterioration. © 2015 Elsevier Ireland Ltd. All rights reserved.

1. Introduction In-hospital cardiac arrests (IHCA) occur infrequently, but are associated with high in-hospital mortality.1–3 Despite this, regular, often frequent, advanced life support (ALS) training is mandatory for many hospital medical staff and nurses across the world. In contrast, studies suggest that the incidence of pre-cardiac arrest deterioration is approximately 10 times that of cardiac arrests.4–7 There is evidence that intervention prior to cardiac arrest can reduce the incidence of IHCA,2,8,9 and that such interventions may also reduce IHCA-related mortality,2,9 possibly because responders can make early decisions about the suitability of resuscitation for patients whose deterioration might otherwise lead to unnecessary cardiopulmonary resuscitation (CPR). We contend that it would be beneficial to reduce the emphasis on widespread ALS training and to increase education in the recognition and response to pre-arrest clinical deterioration.

夽 A Spanish translated version of the abstract of this article appears as Appendix in the final online version at ∗ Corresponding author at: Centre of Postgraduate Medical Research & Education (CoPMRE), Faculty of Health and Social Sciences, Bournemouth University, Royal London House, Christchurch Road, Bournemouth, Dorset BH1 3LT, UK. E-mail address: [email protected] (G.B. Smith). 0300-9572/© 2015 Elsevier Ireland Ltd. All rights reserved.

2. What is known about the epidemiology of in-hospital clinical deterioration? The incidence of IHCA rates can be difficult to interpret because of variability in the definition of IHCA, the denominator used and inclusion/exclusion criteria in published studies.10 Despite these variations, there is evidence that the rate of IHCA is now decreasing,2,8,9 with hospitals seeing between approximately 1 and 5 IHCAs per 1000 admissions.1–3 The UK National Cardiac Arrest Audit (NCAA) recently reported that, in 144 acute hospitals, 22,628 patients aged ≥16 years received chest compressions and/or defibrillation from a hospital-based resuscitation team in a 2-year period (23,554 IHCAs).1 Of these arrests, 13,338 (56.6%) occurred in general hospital wards, giving a mean annual incidence for wardbased arrests of 46 per year per hospital.1 Hence, an individual staff member working on a general ward may only rarely encounter an IHCA. This is an important point because it impacts on the ability of professionals to provide optimal care. IHCAs are associated with an in-hospital mortality of approximately 80%.1–3 This is perhaps not surprising given the findings of observational studies, which show that many IHCAs are preceded by long periods of clinical instability that is unrecognised or inadequately treated.11,12 Most IHCAs are likely to represent the end-stage of progressive organ failure and clinical deterioration, rather than being sudden and unexpected. Furthermore, many


G.B. Smith et al. / Resuscitation 92 (2015) 59–62

patients suffering cardiac arrest are elderly, have significant comorbidity, and arguably, will not benefit from CPR, yet are still subject to an uncomfortable, undignified and, probably, painful intervention.13 In response to these findings, critical care outreach services (CCOS) were introduced in the UK and Australia to provide expertise for deteriorating ward patients.14,15 In addition, a more reactive response model – the Rapid Response Team (RRT) – was introduced in many countries.16 Several studies demonstrate that the frequency of RRT calls to ward patients is 10–100 times that of cardiac arrest calls. A single centre study of a CCOS in Australia revealed that for the 3000 patients reviewed, the in-hospital mortality was 8.9%.4 Furthermore, in a point prevalence study, Bell et al. revealed that the incidence of patients with mild degrees of physiological instability was 13.8%, and that the associated 30-day mortality was 14.6%.5 A recent UK publication demonstrated that the mismanagement of deterioration of acutely ill patients was a feature in 35% of patient-safety reported deaths,17 although this may be an underestimate.18 In hospitals with well-established RRTs, the quoted incidence of patient reviews by the RRTs is in the order of 2–8% of hospital admissions.5–7 Importantly, while the incidence of IHCA may be decreasing, the incidence of RRT calls appears to be increasing.19 The in-hospital mortality of patients subject to RRT review is in the order of 20–25%.7 Therefore, whilst patients suffering IHCAs have a mortality of ∼80%, they affect less than 1% of hospitalised patients. In contrast, the mortality of patients subject to critical care outreach review (approximately 10%) and RRT review (approximately 20%) is substantially lower and occurs 10–100 times more often. Thus, hospitalised patient are more likely to die in the context of RRT and outreach review than in association with review by a cardiac arrest team. This may be related to the fact that approximately one third of all RRT calls are related to end-of-life issues.20 On the other hand, it is important to appreciate that many patients fulfilling clinical criteria requiring escalation to an outreach sevice or RRT will not suffer an adverse event.5 Risk stratifying such patients is challenging.

3. Is there evidence for treatments applied to deteriorating patients? Cardiopulmonary resuscitation (CPR) was originally intended to prevent the premature deaths of patients with “hearts too young to die” – often those with normal hearts undergoing non-cardiac surgery, or patients with minimal or no structural cardiac abnormality suffering sudden ventricular fibrillation (VF).19 However, evidence suggests that CPR has become a reflex ‘routine’ component of the dying process in hospital, even for patients with little or no prospect of hospital discharge (i.e., “patients too sick to live”21 ).13 Indeed, in some areas of the world such an approach is mandated. Furthermore, CPR has become commonplace as a last ditch attempt to save the lives of patients in whom there has been a failure to recognise or respond to clinical deterioration or where there has been sub-optimal end of life care planning.13 Indeed, data from the US suggest that hospitals with higher case-survival rates have a lower incidence of IHCA,22 possibly implying better prevention of IHCA or better selection of candidates for CPR. Current treatment for IHCAs involves a highly protocolised algorithm aimed at achieving early and effective chest compressions, early administration of adrenaline, and early cardiac defibrillation for shockable rhythms.23 High-level evidence for the benefits of many ALS components is scarce, particularly for the use of artificial ventilation, tracheal intubation, and adrenaline.23 In addition, whilst early defibrillation is beneficial for patients with shockable rhythms, many studies suggest that most initial IHCA rhythms are

non-shockable.1,3 In fact, evidence suggests that survival following ward-based IHCA is dependent upon interventions by first responders, not the cardiac arrest team.24,25 In one US study, the number of interventions commenced on the general wards before the team arrived appeared to be the most important factor leading to a reduction in in-hospital mortality.25 In contrast, there is increasing evidence that intervention in the period prior to cardiac arrest can improve patient outcome.2,6,8,9 Recently, Chen et al. reported that progressive implementation of RRTs into an Australian state over 8 years was associated with a 52% decrease in arrest rate, a 55% decrease in arrest related mortality rate, a 23% decrease in hospital mortality rate and a 15% increase in survival to discharge after an IHCA.2 It was estimated that 95% of the reduction in arrest-related mortality was related to reduction in the incidence of arrests, and that only 5% of this improvement could be related to improvements in management once the cardiac arrest had occurred. 4. How do hospitals train their staff for IHCA? ALS training compliant with international cardiopulmonary resuscitation (CPR) guidelines23 provides a significant workload and cost for healthcare providers internationally. According to a recent analysis of CPR training in all US counties, more than 1.2 million persons received training in adult and paediatric ALS skills during a 12-month period.26 It is estimated that the cost of hospital CPR programmes is between $400,000 and 600,000 (US)/cardiac arrest survivor, making it one of the most expensive interventions in medicine.27 Similarly, in the period 2012–2013, approximately 19,000 candidates per year undertook a Resuscitation Council (UK) (RCUK) ALS provider course.28,29 The fee per candidate was approximately £350, creating an estimated total expenditure of approximately £6.6 million per year, even before the cost of replacing staff intraining is taken into account. Most of these courses lasted 2 days and were ‘face-to-face’, requiring the presence of instructors whose time is also rarely included in the course fee. In the UK, US and Australia, national resuscitation training bodies require regular certification in ALS procedures every 2–4 years, and in some hospitals such certification and recertification is mandatory in order to practice. Annual training and education of hospital staff in the elements of ALS is often mandatory, and in several countries this is linked with hospital accreditation. This is despite that fact that many staff will never be involved in a cardiac arrest, and that many of the components of the algorithms lack high level evidence. In addition, there is no evidence that training staff with current programmes can sustain competence. The authors of a recent review of annual resuscitation competency assessments30 concluded that although “. . .common-sense suggests that maintaining an up-to-date knowledge of changes in resuscitation theory based on prevailing and emergent evidence is vital to guide resuscitation performances of clinicians. . ..”, they could find no evidence that annual assessment of theoretical knowledge related to resuscitation improved resuscitation performance. Likewise, they could find no evidence that annual assessment of resuscitation skills improved resuscitation performance. They concluded, “. . .no relationship between assessment and performance has been established, whereas learning/practice and performance is related. . .” 30 5. Is there evidence that training in the recognition and response to clinical deterioration is of benefit? Despite the more frequent occurrence and potential preventability of serious clinical deterioration, there is much less

G.B. Smith et al. / Resuscitation 92 (2015) 59–62 Table 1 Suggested staff training for cardiac arrest.

Table 2 Suggested curriculum for education to prevent and manage clinical deterioration.




Advance life support

Cardiac arrest team members Ward first responders All staff with clinical patient contact All hospital staff with patient contact

ALS course

Ward pre-arrest and arrest situations Patient deterioration

Basic life support


ILS course ALERT-type courses BLS course

obligation on hospitals to provide mandatory training directed towards cardiac arrest prevention. However, there is evidence that education of ward staff in aspects of the early recognition of deterioration and simple clinical interventions (e.g., oxygen, fluids, improved patient posture) can alter staff knowledge and attitudes, and clinical outcomes.31–36 A 1-day multiprofessional course on acute care for ward-based staff – Acute Life threatening Events: Recognition & Treatment (ALERTTM ) has been shown to improve staff knowledge of acute care and attitudes towards managing the deteriorating patient.31,32 It has also been used as a fundamental component of a strategic approach shown to reduce hospital mortality.33 Use of the RCUK’s Immediate Life Support (ILS) course, which focuses on teaching hospital ‘first responders’ the knowledge and skills to identify and treat ‘patients at risk’ and manage those patients in cardiac arrest prior to the arrival of the cardiac arrest team, has demonstrated a close association between the proportion of healthcare professionals who were ILS-trained and the number of emergency calls initiated as pre-arrest calls.9 The authors reported reductions in both the number of cardiac arrests and unsuccessful resuscitation attempts.9 Almost all of the observed reduction in the hospital cardiac arrest rate in one Australian study occurred before the introduction of the medical emergency team (MET) during the period when ward staff were being educated about, and prepared for, its implementation.34,35 Additionally, in a US hospital with an established MET, the introduction of specific, objective criteria for ward staff to activate the MET resulted in improved use of the MET and a significant reduction in cardiac arrests.36 These latter findings34–36 emphasise that education of ward staff is probably essential to facilitate optimal outcomes from rapid response systems. Campello et al. suggested that the critical factor in the effectiveness of a RRS programme was probably “. . .the staff education, awareness, and responsiveness to physiologic instability of the patients. . .”25 6. Cardiac arrest: what, who and how should we teach? We propose that education and training is required to ensure that patients suffering deterioration, pre-arrest states or cardiac arrest are treated effectively and reliably by readily available, suitably skilled, staff. Therefore, staff training should be tailored accordingly, so that individuals can focus on what is really necessary for their particular roles (Table 1), rather than receiving training in skills they are unlikely to use. The precise competencies required by individual members of ward and response team staff to manage acutely ill patients would vary. However, for most, we suggest that they will include the knowledge, skills and attitudes listed in Table 2. Essential components include knowledge of the rapid response system operating in their hospital. All hospital staff with patient contact should probably have regular basic life support (BLS) training. However, the optimal manner in which such training is delivered requires further investigation. Those working on general wards, where an immediate clinical

Rationale for rapid response systems Monitoring requirements of sick patients How to measure physiological parameters correctly Charting of observations – why, how Normal physiological values Recognition of physiological deterioration Assessment and interventional skills Use of the hospital’s ‘track and trigger’ system How and when to call for help (e.g. RSVP or SBAR) Who is in the rapid response team? What is the individual’s role in the rapid response system? Team training – including non-technical skills and crew resource management Human factors pertaining to rapid response systems DNACPR and end-of-life care decision-making

Ward staff √

Response team √

√ √

√ √



√ √

√ √

RSVP, Reason–Story–Vital Signs–Plan; SBAR, Situation–Background–Assessment– Recommendation; DNACPR, Do Not Attempt Cardiopulmonary Resuscitation.

response to pre-arrest or arrest states is required, should be able to recognise deterioration quickly, summon help immediately and apply effective resuscitation techniques (e.g., chest compressions and defibrillation). These skills could be delivered via ILS training, ideally on a mandatory basis. Attendance at ALS courses should be limited to staff that attend cardiac arrests as a cardiac arrest team (CAT) member. Achieving this may be difficult initially, as some individuals, departments, hospitals, and certification bodies have financial and other interests that could conflict with a move away from ALS towards ILS/preventative training. Future planning of cardiac arrest responses should probably focus on making the CAT members permanent in that role, thereby improving the effectiveness of training and teamwork. While an increased emphasis on recognising the deteriorating patient is essential, there remains little evidence about whether training all hospital clinicians in advanced resuscitation is more effective than immediately calling someone with the appropriate skills, knowledge and experience. There needs to be more research on exactly what level of training of every hospital clinician would be effective in improving patient outcome and what would be the resource implications and costs of such training. 7. Conclusions Although IHCAs are associated with an in-hospital mortality of 80%, they are relatively infrequent. Moreover, current interventions to revive an arrested patient lack high-level evidence. There is a need to tailor and individualise BLS and ALS training for hospital staff, and to increase the emphasis on training staff in the recognition of and response to clinical deterioration in the pre-arrest period. Funding Nil.


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Conflict of interest statement Professor Smith is the co-developer of the ALERT® [Acute Life Threatening Events: Recognition and Treatment] course, which is run as an internationally franchised business by Portsmouth Hospitals NHS Trust (PHT). Professor Smith was an employee of PHT until April 2011. Professor Smith does not receive, and has not received, any financial benefit from his involvement as co-developer of ALERT. He is also a current member of the Resuscitation Council (UK) [RCUK] Executive Committee, the RCUK Immediate Life Support (ILS) course steering group and the UK’s National Cardiac Arrest Audit steering group. He is also a past member of the working party and steering group for the Royal College of Surgeons of England’s “Care of Critically ill Surgical Patient” (CCrISP) course, and is past co-chairman and member of the Federation of Royal Colleges of Physicians Working Party for its IMPACT (Ill Medical Patients’ Acute Care & Treatment) course. Professor Jones has received approximately $AU 6000 for advice to public hospitals regarding deteriorating patients in the past 3 years. He was the principle investigator for a funded study from the ACSQHC but did not receive personal payment from this grant. References 1. Nolan JP, Soar J, Smith GB, et al. Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Resuscitation 2014;85:987–92. 2. Chen J, Ou L, Hillman KM, et al. Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion. Med J Aust 2014;201:167–70. 3. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14 720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58:297–308. 4. Mcintyre T, Taylor C, Reade M, Jones D, Baldwin I. Characteristics and outcomes of patients subject to intensive care nurse consultant review in a teaching hospital. Crit Care Resusc 2013;15:134–40. 5. Bell MB, Konrad D, Granath F, Ekbom A, Martling CR. Prevalence and sensitivity of MET-criteria in a Scandinavian University Hospital. Resuscitation 2006;70:66–73. 6. Jones D, Bellomo R, DeVita MA. Effectiveness of the Medical Emergency Team: the importance of dose. Crit Care 2009;13:313. 7. Jones D. The epidemiology of adult rapid response team patients in Australia. Anaesth Intensive Care 2014;42:213–9. 8. Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham JC, Dy SM. Rapid-response systems as a patient safety strategy. A systematic review. Ann Intern Med 2013;158:417–25. 9. Spearpoint KG, Gruber PC, Brett SJ. Impact of the Immediate Life Support course on the incidence and outcome of in-hospital cardiac arrest calls: an observational study over 6 years. Resuscitation 2009;80:638–43. 10. Sandroni C, Nolan J, Cavallaro F, Antonelli M. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Med 2007;33:237–45. 11. Franklin C, Mathew J. Developing strategies to prevent inhospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med 1994;22:244–7. 12. Kause J, Smith GB, Hillman K, Prytherch D, Parr M, Flabouras A. Antecedents to cardiac arrest, deaths and emergency intensive care admissions – the ACADEMIA study. Resuscitation 2004;62:275–82.

13. National Confidential Enquiry into Patient Outcomes and Death. Time to Intervene? A review of patients who underwent cardiopulmonary resuscitation as a result of an in-hospital cardiorespiratory arrest. London: National Confidential Enquiry into Patient Outcome and Death; 2012. 14. Bright D, Walker W, Bion J. Clinical review: outreach – a strategy for improving the care of the acutely ill hospitalized patient. Crit Care 2004;8:33–40. 15. Eliott S, Chaboyer W, Ernest D, Doric A, Endacott R. A national survey of Australian Intensive Care Unit (ICU) Liaison Nurse (LN) services. Aust Crit Care 2012;25:253–62. 16. Jones DA, DeVita M, Bellomo R. Rapid-response teams. N Engl J Med 2011;365:139–46. 17. Donaldson LJ, Panesar SS, Darzi A. Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010–2012. PLOS Med 2014;11:e1001667. 18. DeVita MA, Smith GB, Welch J, Hillman K. Patient-safety-related hospital deaths in England. PLOS Med 2014. listThread.action?root=81365 [accessed 14.02.03=2105]. 19. ANZICS-CORE MET Dose Investigators. Mortality of rapid response team patients in Australia: a multi-centre study. Crit Care Resusc 2013;15:273–8. 20. Jones D, Bagshaw SM, Barrett J, et al. The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study. Crit Care Med 2012;40:98–103. 21. Eisenberg M. Resuscitate!: How your community can improve survival from sudden cardiac arrest. A completed life. p. 160–167 [Chapter 8]. 22. Chen LM, Nallamothu BK, Spertus JA, Li Y, Chan PS, American Heart Association’s Get With the Guidelines-Resuscitation (formerly the National Registry of Cardiopulmonary Resuscitation) Investigators. Association between a hospital’s rate of cardiac arrest incidence and cardiac arrest survival. JAMA Intern Med 2013;173:1186–95. 23. International consensus on cardiopulmonary resuscitation and emergency care science with treatment recommendations. Resuscitation 2010;81(Suppl.):e1–332. 24. Soar J, McKay U. A revised role for the hospital cardiac arrest team? Resuscitation 1998;38:145–9. 25. Campello G, Granja C, Carvalho, Dias C, Azevedo LF, Costa-Pereira A. Immediate and long-term impact of medical emergency teams on cardiac arrest prevalence and mortality: a plea for periodic basic life-support training programs. Crit Care Med 2009;37:3054–61. 26. Anderson ML, Cox M, Al-Khatib SM, et al. Rates of cardiopulmonary resuscitation training in the United States. JAMA Intern Med 2014;174:194–201. 27. Lee KH, Angus DC, Abramson NS. Cardiopulmonary resuscitation: what cost to cheat death? Crit Care med 1996;24:2046–52. 28. Resuscitation Council (UK) Newsletter; 2013. newsletr/nletr13S.pdf [accessed 28.01.15]. 29. Resuscitation Council (UK) guidelines development process manual. Appendix 1 – organisational cart and statistics; 2014. Manual.pdf [accessed 28.01.15]. 30. Allen JA, Currey J, Considine J. Annual resuscitation competency assessments: a review of the evidence. Aust Crit Care 2013;26:12–7. 31. Smith GB, Poplett N. Impact of attending a 1-day multi-professional course (ALERT) on the knowledge of acute care in trainee doctors. Resuscitation 2004;61:117–22. 32. Featherstone P, Smith GB, Linnell M, Easton S, Osgood VM. Impact of a oneday inter-professional course (ALERT) on attitudes and confidence in managing critically ill adult patients. Resuscitation 2005;65:329–36. 33. Wright J, Dugdale B, Hammond I, et al. Learning from death: a hospital mortality reduction programme. J R Soc Med 2006;99:303–8. 34. Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Med J Aust 2003;179:283–7. 35. Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Med J Aust 2004;180:310. 36. DeVita MA, Braithwaite RS, Mahidhara R, et al. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care 2004;13:251–4.

Education for cardiac arrest--Treatment or prevention?

In-hospital cardiac arrests (IHCA) occur infrequently and individual staff members working on general wards may only rarely encounter one. Mortality f...
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