This article made the rounds a couple weeks ago in the news media, probably based on the conclusion from the abstract stating “efforts to systematically increase the duration of resuscitation could improve survival in this high-risk population.”
They base this statement off a retrospective review of prospectively gathered standardized data from in-hospital cardiac arrests. Comparing 31,000 patients with ROSC following an initial episode of cardiac arrest with a cohort of 33,000 who did not have ROSC – the authors found that patients who arrested at hospitals with higher median resuscitation times were more likely to have ROSC. Initial ROSC was tied to survival to discharge, where hospitals with the shortest median resuscitation time having a 14.5% adjusted survival compared to 16.2% at hospitals with the longest resuscitations.
Now, if you’re a glass half-full sort of person, “could improve survival” sounds like an endorsement. However, when we’re conjuring up hypotheses and associations from retrospective data, it’s important to re-read every instance of “could” and “might” as “could not” and “might not”. They also performed a horde of patient-related covariates, which gives some scope of the difficulty of weeding out a significant finding from the confounders. The most glaring difference in their baseline characteristics was the 6% absolute difference in witnessed arrest – which if not accounted for properly could nearly explain the entirety of their outcomes difference.
It’s also to consider the unintended consequences of their statement. What does it mean to continue resuscitation past the point it is judged clinically appropriate? What sort of potentially well-meaning policies might this entail? What are the harms to other patients in the facility if nursing and physician resources are increasingly tied up in (mostly) futile resuscitations? How much additional healthcare costs will result from additional successful ROSC – most of whom are still not neurologically intact survivors?
“Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study“
www.thelancet.com/journals/lancet/article/PIIS0140…9/abstract
In addition to everything you mention, my other problem with this article is that it completely misses the big issues surrounding in-hospital cardiac arrest. It should be well known by now that the only outcome-changing practices during CPR are minimizing interruptions and early defibrillation. However, in my experience responding to codes in-house, the focus often ends up being everything but. We need to make our resuscitations upstairs more efficient, not longer. Maybe I'm looking in the wrong places, but I've seen hardly any studies specifically looking at improving the quality of in-hospital cardiac arrest resuscitation.
More and more prehospital systems are realizing the importance of these interventions, with increasing survival data to support that movement, but I just don't see the same focus on what actually works in the hospital. I've reached the point where I almost think we should stop stocking central line kits, and maybe even intubation supplies, on our crash carts, but the resulting panic to track them down when someone demands one would be an even bigger distraction than the actual procedures.
The "Work Longer, Not Smarter" study!
It's concerning that this study, or at least the publicity surrounding it, has generated discussion amongst our paramedics about whether we should alter our termination-of-resuscitation guidelines. It's worth pointing out, therefore, that this study excluded ED and prehospital arrests.
I addressed some of this in my own review (http://millhillavecommand.blogspot.com/2012/09/should-we-increase-duration-of-cpr.html), but your analysis gets to the issues with far less verbiage!
I like the idea of simplifying the crash cart down to electricity and a metronome for CPR! Of course, there's more to medical codes than pulselessness. And, I guarantee the comfort level of inpatient folks vs. the ED with codes/code meds/resuscitation is not nearly as high.
As far as pre-hospital guidelines – most of the literature I've seen supports increasing field termination of resuscitative efforts. This could all change with advances in preventing post-arrest neurologic damage, but for now, saving more is frequently the temporary "…but what have we really saved?"