All that arrests is not cardiac: pre-arrest care
Michael Parr
Intensive Care Unit, Liverpool Hospital, Sydney South West Area Health Service, Sydney, Australia, University of New South Wales, Sydney, Australia
ABSTRACT
Outcome from in-hospital cardiac arrest outside of coronary care units remains poor despite the introduction of cardiac arrest teams. The deterioration to in-hospital cardiac arrest is usually not sudden, is often predictable and is preceded by signs of significant physiological instability for several hours. There are often deficiencies in simple aspects of care including: the failure to treat abnormalities of the patient's airway, breathing and circulation, incorrect use of oxygen therapy, failure to monitor patients, failure to involve experienced senior staff, poor communication, lack of teamwork and insufficient use of treatment limitation plans. It is this time-period that provides an opportunity for early recognition and treatment.
Based on the available evidence in 2005 the International Liaison Committee on Resuscitation (ILCOR) recommended that the “Introduction of a Medical Emergency Team (MET) system for adult hospital in-patients should be considered, with special attention to details of implementation (e.g. composition and availability of the team, calling criteria, education and awareness of hospital staff, and method of activation of the team). Introduction of an Early Warning System (EWS) system for adult in-hospital patients may be considered.” MET is not the only system that can be used to track, trigger and intervene in critical illness but it is the one associated with the most literature. This recommendation has been repeated by the European Resuscitation Council in Guidelines for Resuscitation 2005 while outlining the following strategies to prevent avoidable in-hospital cardiac arrests.
1. Provide care for patients who are critically ill or at risk of clinical deterioration in appropriate areas, with the level of care provided matched to the level of patient sickness.
2. Critically ill patients need regular observations: match the frequency and type of observations to the severity of illness or the likelihood of clinical deterioration and cardiopulmonary arrest. Often only simple vital sign observations (pulse, blood pressure, respiratory rate) are needed.
3. Use an EWS system to identify patients who are critically ill and or at risk of clinical deterioration and cardiopulmonary arrest.
4. Use a patient charting system that enables the regular measurement and recording of EWS.
5. Have a clear and specific policy that requires a clinical response to EWS systems. This should include advice on the further clinical management of the patient and the specific responsibilities of medical and nursing staff.
6. The hospital should have a clearly identified response to critical illness. This may include a designated outreach service or resuscitation team (e.g. MET) capable of responding to acute clinical crises identified by clinical triggers or other indicators. This service must be available 24 h per day.
7. Train all clinical staff in the recognition, monitoring and management of the critically ill patient. Include advice on clinical management while awaiting the arrival of more experienced staff.
8. Identify patients for whom cardiopulmonary arrest is an anticipated terminal event and in whom CPR is inappropriate, and patients who do not wish to be treated with CPR. Hospitals should have a DNAR policy, based on national guidance, which is understood by all clinical staff.
9. Ensure accurate audit of cardiac arrest, ‘false arrest’, unexpected deaths and unanticipated ICU admissions using common datasets. Audit also the antecedents and clinical response to these events.
REFERENCES
European Resuscitation Council Guidelines for Resuscitation 2005. Section 4. Adult advanced life support. Resuscitation 2005; 67S1: S39-S86. http://www.erc.edu/index.php/guidelines_download_2005/en/
International Liaison Committee on Resuscitation. Part 4. Advanced life support. Resuscitation 2005; 67: 213-247. http://www.erc.edu/index.php/guidelines_download_2005/en/
Peberdy MA, Kaye W, Ornato JP, Larkin GL, Nadkarni V, Mancini ME, Berg RA, Nichol G, Lane-Trultt T. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003; 58: 297-308.
Kause J, Smith G, Prytherch D, Parr M, Flabouris A, Hillman K. A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom – the ACADEMIA study. Resuscitation 2004; 62: 275-282.
Parr MJA, Hadfield JH, Flabouris A, Bishop G, Hillman K. The medical emergency team: 12 month analysis of reasons for activation, immediate outcome and not-for-resuscitation orders. Resuscitation 2001;50: 39-44
Cretikos M, Parr M, Hillman K et al. Guidelines for the Uniform Reporting of Data for Medical Emergency Teams. Resuscitation 2006;68:11-25
Time of Presentation
1330
