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Prevention of Complications in Hospitalized Patients Part VII: Cardiac Arrest

Author: Kevin S. Breger, M.D., Nasim Afasarmanesh, M.D. and Michael S. Galindo, M.D.

Last Revised: Wed, 22-Apr-2009

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CLINICAL REVIEW

Prevention of Complications in Hospitalized Patients Part VII: Cardiac Arrest

Kevin S. Breger, M.D., Nasim Afasarmanesh, M.D. and Michael S. Galindo, M.D.

The Clinical Scenario

A 76-year-old woman with a history of hypertension, hyperlipidemia, and diabetes is admitted with a urinary tract infection associated with mild hypotension. She is put on the telemetry unit for continuous cardiac monitoring and is treated with intravenous fluids and antibiotics. On the second hospital day, she remains tachycardic, hypotensive, and tachypneic while becoming increasingly somnolent. Early on the third hospital day, she is found unresponsive and pulseless. There is no advance directive in the patient's chart. A "Code Blue" is called, and she expires despite a vigorous attempt to resuscitate her. Are there any interventions that might have prevented this unanticipated in-hospital cardiopulmonary arrest?

Introduction

Cardiopulmonary arrest is the sudden cessation of effective cardiac pumping as a result of either ventricular asystole, pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF).¹There are an estimated 300,000 to 400,000 deaths a year from sudden cardiac death.²Cardiopulmonary arrest is an uncommon complication during admission to the hospital, occurring in 0.6% to 1.4% of all medical patients discharged from a hospital.³Although uncommon compared to other complications of hospitalization, the mortality and morbidity from in-hospital arrest is enormous.

Cardiac arrest is strongly correlated with coronary artery disease, which is present in 50% to 80% of people older than 35 years sufferring from cardiac arrest.⁴Pre-existing cardiomyopathies or a history of prior myocardial infarction both can act as a source of deadly arrythmias. On this background of preexisting disease, cardiac arrest can be triggered by clinical conditions that put further strain on the myocardium, such as respiratory failure or hypotension.

Cardiopulmonary resuscitation (CPR) was endorsed by the American Heart Association in 1963 and is the mainstay of treatment for a patient who is found to have a cardiac arrest, whether it occurs in or out of the hospital. Despite widespread training in CPR for physicians, nurses, and lay people, outcomes from CPR remain poor.⁵These outcomes most commonly include death, prolonged hospitalizations, or neurological compromise. A large meta-analysis encompassing 30 years of data showed that only 15% of approximately 20,000 patients with in-hospital cardiac arrest survived to discharge.⁵Strikingly, this low survival rate was consistent over a nearly 30 year span despite other advances in medicine. Further, there is markedly worse survival to hospital discharge in patients older than 89 years.⁵

Studies of in-hospital cardiac arrest and resuscitation have been difficult to standarize and interpret; therefore, recent work has focused on developing a national registry (NRCPR).⁶Initial results from a modern cohort of more than 14,000 in-hospital cardiac arrests found that overall survival to hospital discharge was 17%. Another recent study published an 18% survival to discharge rate.⁷In the NRCPR database, patients with pulseless ventricular tachycardia and ventricular fibrillation fared better (~35% survival to discharge) than patients whose initial rhythm was asystole or pulseless electrical activity (10% survival to discharge).⁶This survival difference is directly related to the fact that defibrillation is effective for patients with VT/VF but not for asystole or pulseless electrical activity. Unfortunately, due to the increasing comorbidities of the modern hosptialized patient, VT and VF are declining in incidence as the initial rhythm in cardiac arrests while asystole and pulseless electrical activity are increasing. This inauspicious shift in rhythms creates fewer opportunities for successful defibrillation and resuscitation.⁷

Untreated VT/VF degenerates into asystole, emphasizing that prompt recognition of patients with VT/VF is critical in reducing mortality and morbidity from cardiac arrest. In cases of VT/VF, delivering electrical defibrillation greater than three minutes after onset is associated with almost a 50% relative reduction in survival to discharge.⁶

Even with modern CPR techniques, outcomes after cardiac arrest are poor. Investigators have proposed a number of methods aimed at preventing in-hospital cardiac arrest including the use of continuous cardiac monitoring, applying "illness scores" to identify patients at highest risk for cardiopulmonary arrest, and implementing medical emergency teams (MET) or rapid response teams (RRT). Another intervention commonly employed to prevent cardiac arrest includes suppression of arrythmogenic potential with aggressive replacement of potassium and magnesium. In addition, improved education for healthcare workers in recognizing and implementing early critical care level interventions has been advocated.⁸Finally, initiating frank discussions with patients and families about advanced directives and end-of-life care early in the hospital course has been proposed to avoid futile resuscitation efforts. This review will focus on the evidence supporting or refuting each of the above interventions as effective ways of preventing unanticipated in-hospital cardiopulmonary arrest.

Continuous Cardiac Monitoring

In-hospital continuous cardiac monitoring (CCM) came into favor in the 1960s after it was recognized that ventricular arrhythmias were a major cause of death in patients who had recently experienced a myocardial infarction. With post-myocardial infarction CCM, the mortality from arrhythmia was reduced by approximately 30%.^9-11These results led to the widespread use of CCM in cardiac critical care units. Now, CCM is applied to various patient populations and used extensively throughout hospitals in intensive care units, post-operative units, "stepdown" floors, and emergency departments. The American College of Cardiology and Emergency Cardiac Care Committee^12,13has published guidelines for the use of CCM that balance a patient's risk of arrhythmia against the benefit of monitoring by stratifying patients into 3 risk classes (Table 1).¹³

Few studies have evaluated the usefulness of CCM outside of the critical care setting. There have been no randomized trials comparing outcomes of monitored versus non-monitored patients. Critics of CCM point out that it increases patients' wait times for beds, contributing to overcrowding in emergency rooms. In addition, the wider use of telemetry comes at increased economic cost without clear benefit. Lastly, unnecessary monitoring may inadvertently decrease patients' mobility by tethering them to their beds.

In a retrospective analysis there were only 20 cardiac arrests during 8,932 admissions to a telemetry ward. Of these 20 patients, 16 were on a cardiac monitor at the time of the arrest, and the monitor signaled arrest in only 9 cases. Three patients survived to discharge, two of which had their cardiac arrest detected by the monitor. The authors concluded that telemetry was not helpful in preventing cardiac arrest given that only 0.02% (2/8932) of all the patients on monitor had a detected arrest leading to survival.¹⁴
A study by Estrada et al¹⁵measured whether findings on cardiac monitoring play a role in transfers to an intensive care unit (ICU). In a prospective analysis, the authors found that out of 467 patients in monitored beds, 38 (8%) were eventually transferred to the ICU. Five of the 38 patients were transferred based on a detected arrhythmia (1% of the total study population). The majority of ICU transfers were based on other clinical markers of deterioration and not by telemetry abnormalities. A second, larger study of 2,240 patients by Estrada et al corroborated these findings. An arrhythmia detected on telemetry resulted in transfer to an ICU in only 0.8% of all patients admitted to a telemetry unit, and in only 0.3% of patients with a chest pain syndrome.¹⁶These findings are in accord with other studies that have concluded that monitoring is over-used and unnecessary in low-risk patients with chest pain admitted to "rule out" myocardial infarction.^17,18The low rate of arrhythmia in low-risk chest pain patients has led the American Heart Association to modify its telemetry guidelines and place patients with chest pain into risk class II.¹³
In summary, continuous cardiac monitoring for general medicine patients is not helpful in preventing cardiac arrest. Moreover, transfers to an intensive care unit are usually determined by clinical markers other than arrhythmias detected on telemetry.

Early Warning Scores

Because in-hospital cardiac arrest is a rare event and has such poor outcomes when it occurs, efforts have been made to predict which patients are most prone to this complication. Interestingly, most in-hospital cardiac arrests are preceded by a notable clinical deterioration. While recognition of cardiac arrest appears to occur suddenly (i.e. a patient is "found down"), the arrest is more often the terminal event for a number of serious medical processes that share common physiological pathways.^19-21In 51% to 86% of ward patients who suffered a cardiopulmonary arrest, several critical physiologic changes have been described preceding the arrest.^19-21Strikingly, these physiologic perturbations are present for longer than 24 hours in the majority of patients.²²Further, studies show that healthcare staff, including physicians, often do not respond to warning signs in a timely manner.^19,20,23

Using early warning scores has the potential to decrease the delay in identifying and treating an unstable patient, which is one of the largest challenges of cardiac arrest prevention. Many studies have documented a lack of adequate clinical response to a patient's changing clinical status.²¹The lack of response is multi-factorial and includes defects in nurses notifying physicians, delay in physicians responding to nurses concerns, delays in notifying critical care specialists, and lack of appropriate stabilization of a patient prior to transferring to the intensive care unit.^21,24One study showed that nurses did not notify a physician in 25% of cardiac arrests preceded by a documented change in a patient's clinical status. In almost 40% of cardiac arrests in which the physician was notified, the critical care team was not called prior to the arrest. In nearly 70% of cases of cardiac arrest cases in which the primary physician notified the ICU, the arrest occurred prior to physically transferring the patient to the ICU. One benefit of instituting a standardized scoring system is its effect on awareness and education of nursing staff and physicians that some subtle findings in a patient may add up to a higher risk of mortality.²⁵

To simplify the detection of deteriorating patients, a Modified Early Warning Score (MEWS) was developed (Table 2).²⁶Five clinical parameters of systolic blood pressure, heart rate, respiratory rate, temperature, and neurologic status are scored independently and summed to provide a score. There has not been a randomized trial to validate the MEWS and its developers caution that it was not designed to be a predictor of outcome.²⁷Despite these caveats, a prospective observational study showed that patients with MEWS of 3 to 4 had an increased incidence of cardiopulmonary arrest when compared to patients with lower MEWS.^28,29Another study expanded the MEWS to include oxygen saturation, a physiologic parameter that is an independent predictor of mortality³⁰as a sixth metric, and renamed it the standardized early warning system (SEWS)(Table 2). In a small beforeand-after prospective non-randomized trial, the SEWS score at admission had a linear correlation with hospital length of stay and in-hospital mortality. Specifically, a patient with a score greater than or equal to 4 on admission had a 1-in-6 risk of in-hospital death.²⁵
These reports of success with early warning scores has led to a movement to develop "track and trigger" policies whereby physiologic signs are monitored and a change in patient care is "triggered" if a certain threshold is crossed. Overall, early warning systems have poor sensitivity but reasonable specificity, and efforts are being made to determine which signs will be most useful in routine clinical care.³¹
Early warning scoring systems have limitations, and a strict numerical cut-off alone is unlikely to be applicable to a wide variety of patients and clinical scenarios that arise in a hospital. However, we conclude that implementing an early warning scoring system can be a helpful adjunct for physicians and nursing staff in identifying those patients at highest risk for clinical deterioration. Such a system may prevent delays in treatment and triage, and possibly prevent cardiac arrest.

Medical Emergency Teams/Rapid Response Teams

A third major initiative to prevent in-hospital cardiac arrest is the medical emergency team (MET) or rapid response team (RRT), which are based on the premise that early intervention in a critically ill patient may prevent further deterioration. Typically, the MET is composed of a combination of physicians, nurses, respiratory therapists, and other ancillary hospital staff who can be summoned within a short time to a patient's bedside, perform an assessment of the patient, begin advanced resuscitation measures, or initiate a transfer to an ICU. Personnel capable of activating the MET within the hospital include anyone caring for the patient including doctors, nurses, or other staff. In some institutions, even patients' families are able to activate the MET. Criteria for when to activate the MET have varied between studies but in general use predefined critical perturbations in vital signs or healthcare staff perception of a change in the patient's clinical status.

Medical emergency team implementation is intuitively appealing, and in some early, single-center studies, was shown to be beneficial. In recent studies, though, the effect of METs on mortality and cardiac arrest prevention has not been favorable. However, some of these studies did not have proper control groups. The majority of studies on MET have been observational,³²typically comparing mortality and/or cardiac arrest rates within an institution before and after implementation of a MET.
Two cluster-randomized trials have been performed in which a group of hospitals with a MET were compared to a group without a MET. The highly anticipated large, multi-centered, international trial by Hillman et al (MERIT study),³³failed to show a difference in mortality or cardiac arrest rates in hospitals with METs. This study has been criticized because many patients who satisfied criteria for MET activation did not have the MET called, possibly underestimating any beneficial effect.^23,33The difficulty in implementing MET across a number of hospitals highlights the problem that adherence to a new model of healthcare may be difficult despite extensive education about how to use it properly.
Despite early excitement regarding METs, the only randomized controlled trial to study cardiac arrest prevention failed to show a benefit. The results of the MERIT trial call into question the push by prominent medical advisory committees and boards (Institute for Healthcare Improvement, American Association of Medical Colleges, Joint Commission on the Accreditation of Healthcare Organizations) to widely implement MET or rapid response teams based on the results of smaller, non-randomized trials.³²A recent Cochrane database review concluded that METs have not shown a benefit and has called for more randomized controlled trials to further investgate their effectiveness.³⁴

Electrolyte Replacement

Guidelines have been published for the treatment of hypokalemia in the setting of specific co-morbidities. In asymptomatic, low risk patients, potassium should be replaced when the serum potassium level is below

3.0 mmol/L because cardiac arrest and arrhythmias are rare in the absence of underlying heart disease. However, potassium levels should be maintained above 4.0 mmol/L in patients with acute myocardial infarction, myocardial ischemia, congestive heart failure, cardiomyopathy, hypertension, left ventricular hypertrophy, or anti-arrhythmic or digitalis medications.³⁵Magnesium levels should be maintained above 2.0 mmol/L in this higher risk population as well, in order to facilitate potassium uptake.

Advance Care Planning

One way to prevent the morbidity associated with in-hospital cardiac arrest is to properly identify those patients who would not want to be resuscitated in the event of a cardiopulmonary arrest. Studies show that there is limited communication between physicians and patients regarding preferences for resuscitation.³⁶The barriers to adequate utilization of advance directives are complex. First, the majority of patients do not want to discuss resuscitation status.³⁷Further, the difficulty in reliably predicting a patient's clinical hospital course in non-oncologic conditions greatly hampers advance care planning. Lastly, there is a misconception that advance directive planning should be handled by a patient's primary care provider despite evidence that short structured discussions in the hospital are effective.^38,39

It is noteworthy that increasing physicians' awareness of their patients' prognoses and potential outcomes of CPR did not improve patient-physician communication.³⁶A recent systematic review of research on improving palliative care found that a multi-pronged approach was beneficial to increase advance directive use.⁴⁰These interventions included involving not just patients but also the caregivers and the medical providers in discussions about goals of care. In addition, having skilled facilitators conduct structured interviews and engaging the patient's value system were found to be most helpful. Given the high morbidity and mortality associated with resuscitative efforts, we recommend that frank discussions regarding resuscitation preferences be initiated with patients and their surrogates at the time of admission so that unwanted resuscitative efforts can be avoided.

Conclusions

Cardiac arrest is a rare complication of admission to the hospital. When it does occur, CPR is the mainstay of treatment in appropriate cases. Multiple interventions to anticipate and prevent cardiac arrest have been developed. Continuous cardiac monitoring, though widely employed, is of limited value in preventing in-hospital cardiac arrest for the general medicine patient. Early attention to the clinical instability that presages a cardiac arrest is likely to be more significant. Therefore, early warning scores, such as MEWS or SEWS, may be helpful in alerting health-care staff to those patients at highest risk of in-hospital mortality. While the development of emergency response teams is intuitively appealing, further randomized trials are needed before determining how to best use this new innovation. Finally, open discussions with patients regarding their wishes for resuscitation should occur at the time of admission or when their clinical status deteriorates.

Summary of Recommendations

Use of continous cardiac monitoring should be restricted to those indications outlined in the AHA guidelines (Table 1).

Consider avoiding cardiac monitoring in patients with low risk chest pain syndrome or low risk syncope.

Educate healthcare staff that cardiac arrests are often preceded by abnormal clinical findings (Table 2).

Consider implementing a standarized early warning scoring (SEWS) system to systematically identify those patients at highest risk of in-hospital mortality.

Await further clinical trial data prior to implementing a medical emergency response team.

Clarify patient's wishes for resuscitation at the time of admission and properly document any who declare themselves "Do Not Resuscitate".

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Submitted on October 23, 2008

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