Hospital Cardiac Arrest Response Often Too Slow

When patients in the hospital suddenly go into cardiac arrest, the staff often takes too long to respond, increasing the risk of brain damage and death, a new study finds.

Delayed Time to Defibrillation after In-Hospital Cardiac Arrest (NEJM)

The research, being published on Thursday in The New England Journal of Medicine, has implications for several hundred thousand people a year in the United States

Doctors analyzed the records of 6,789 patients at 369 hospitals whose hearts stopped because of conditions that could be reversed with an electrical shock from a defibrillator — a favorite device in TV hospital dramas, when a “code blue” is called and doctors and nurses come running with a crash cart and paddles to shock the victim back to life.

In the real world, doctors and nurses do not always run fast enough. Expert guidelines say the shock should be given within two minutes after the heart stops, but the study found that it took longer in 30 percent of the cases. The consequences were striking. When the defibrillation was delayed, only 22.2 percent of the patients survived long enough to be discharged from the hospital, as opposed to 39.3 percent when the shock was given on time.

Delays were more likely in patients whose hearts stopped at night or on the weekend, who were admitted for noncardiac illnesses, in hospitals with fewer than 250 beds and in units without heart monitors.

Nationwide, the problem may be even worse, with delays more common than the 30 percent figure in the study, said Dr. Paul S. Chan, an author of the report, from Saint Luke’s Mid-America Heart Institute in Kansas City, Mo., and the University of Michigan. He said the hospitals in the study probably performed better than average, because all had joined a national registry on cardiac arrest, meaning that they were already putting special efforts into trying to meet resuscitation guidelines.

The registry, created by the American Heart Association, keeps the data anonymous, Dr. Chan said, so it not possible to name hospitals that performed especially well or poorly in the study.

In an editorial accompanying the study, Dr. Leslie A. Saxon, the chief of cardiology at the University of Southern California, said most people probably assumed that a hospital would be the safest place to have a cardiac arrest. But, she said, the assumption turns out to be incorrect.

“I think it’s something doctors have always known but not thought about,” she said, adding that Dr. Chan’s team had conducted a “great study” that would help doctors recognize the problem.

“This is the kind of data we need to say, let’s make sure these preventable things never happen on our watch,” Dr. Saxon said.

From 370,000 to 750,000 hospitalized patients have a cardiac arrest and undergo resuscitation every year in the United States. In about half, the arrest is caused by an abnormal, too-fast rhythm that can be corrected with a shock, Dr. Chan said; the rest need drugs or other treatments.

Dr. Chan said: “We know what works, what saves lives. We have the technology available, and certainly the knowledge and skilled personnel in the hospital to shock patients back to normal rhythm.”
But it will take “political will” for hospitals to put those resources to better use, he said.
Dr. Chan said researchers thought they knew some of the reasons for delays. Sometimes, he said, especially nights and weekends, not enough personnel were available. In some hospitals, nurses outside the intensive care unit are not allowed to use defibrillators, and must wait for a doctor to show up.

“In a small hospital in the middle of the night, the only doctor may be in the emergency room,” Dr. Chan said.

He said hospitals with the best track records might keep their staffs sharp by conducting resuscitation drills or “mock codes,” and might have rapid-response teams, which are specially trained groups that take care of all cardiac arrests.

Another factor is the type and amount of resuscitation equipment available, he said. Traditional defibrillators used in hospitals require that a doctor or nurse look at the patient’s electrocardiogram, verify that the problem is “shockable,” adjust the machine and deliver the shock.

By contrast, the automatic defibrillators that have come into use in public places like airports and casinos during the past decade or so are meant to be used by ordinary people — trained employees or even bystanders. Connected to the chest of someone who has collapsed, the machine senses electrical activity in the heart and delivers a shock only if it is needed. These devices are designed to be essentially foolproof and to make it impossible to harm someone by firing off an unnecessary shock.

Dr. Saxon said the technology existed to offer more people the type of heart monitoring now given mostly to cardiac patients. Not everyone needs it, she said, but it may be in order for those who are very ill with kidney problems, diabetes or pneumonia, even without a history of heart problems. Their information would be transmitted to a computer network that would send out an alert if needed. In addition, she said, automatic defibrillators could be installed in every hospital room.

“You can get them for $500 on eBay,” she said. “It wouldn’t even take a nurse. You could train the cafeteria workers if you wanted to.”