Elsevier

Resuscitation

Volume 85, Issue 1, January 2014, Pages 82-87
Resuscitation

Clinical Paper
The effect of adherence to ACLS protocols on survival of event in the setting of in-hospital cardiac arrest

https://doi.org/10.1016/j.resuscitation.2013.09.019Get rights and content

Abstract

Aim

Advanced Cardiac Life Support (ACLS) algorithms are the default standard of care for in-hospital cardiac arrest (IHCA) management. However, adherence to published guidelines is relatively poor. The records of 149 patients who experienced IHCA were examined to begin to understand the association between overall adherence to ACLS protocols and successful return of spontaneous circulation (ROSC).

Methods

A retrospective chart review of medical records and code team worksheets was conducted for 75 patients who had ROSC after an IHCA event (SE group) and 74 who did not survive an IHCA event (DNS group). Protocol adherence was assessed using a detailed checklist based on the 2005 ACLS Update protocols. Several additional patient characteristics and circumstances were also examined as potential predictors of ROSC.

Results

In unadjusted analyses, the percentage of correct steps performed was positively correlated with ROSC from an IHCA (p < 0.01), and the number of errors of commission and omission were both negatively correlated with ROSC from an IHCA (p < 0.01). In multivariable models, the percentage of correct steps performed and the number of errors of commission and omission remained significantly predictive of ROSC (p < 0.01 and p < 0.0001, respectively) even after accounting for confounders such as the difference in age and location of the IHCAs.

Conclusions

Our results show that adherence to ACLS protocols throughout an event is correlated with increased ROSC in the setting of cardiac arrest. Furthermore, the results suggest that, in addition to correct actions, both wrong actions and omissions of indicated actions lead to decreased ROSC after IHCA.

Introduction

The American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) algorithms are the standard of care for patients suffering cardiac arrest. Although previous reviews did not demonstrate the expected improvement in survival for cardiac arrests of all types, a recent review of 2000–2009 did show an improvement in both return of spontaneous circulation (ROSC) and survival-to-discharge rates.1, 2, 3 It remains unclear how much of the recent improvement is attributable to improved training and adherence to specific algorithms as compared to other improvements, such as in the recommended ACLS algorithms themselves or earlier detection of cardiac arrests.

The presence of ACLS-trained personnel during cardiac arrest increases the likelihood of ROSC and is correlated with significantly better 1-year survival rates.4 Additionally, the presence of an anesthesiologist has been shown to reduce failure to rescue rates in emergency resuscitation situations.5 While key personnel are important, adherence to the specific content and timing of guidelines is often poor.6 The time to defibrillation during in-hospital cardiac arrest (IHCA) is often delayed, which is correlated with worse outcome.7 There is less robust data on the importance of the choice and timing of the medications, and the relationship between overall ACLS algorithm adherence throughout an entire IHCA event and patient outcome has not been documented.7, 8 Accordingly, we compared adherence to the 2005 AHA ACLS algorithms between initial survivors and non-survivors of IHCA. We hypothesized that adherence to the ACLS protocols would be significantly different between the two cohorts.

Section snippets

Methods

After the institutional review board approved this study and waived the requirement for written informed consent, a retrospective chart review of adherence to the 2005 AHA ACLS protocols during IHCAs was performed. Information was gathered on all in-hospital cardiac arrests between 2006 and 2008.

Results

Demographics were not significantly different between groups except for age. There were no differences in sex (p = 0.13), BMI (p = 0.70), race (p = 0.89)), or training level of the team leader (p = 0.38) between groups. There was a significant difference in the average age between the two groups. The SE group averaged 7 years older than the DNS group (59.95 ± 1.94 vs. 52.36 ± 2.19, p < 0.05). The SE group also had significantly higher expected mortality (0.28 ± 0.23 vs. 0.19 ± 0.22, p < 0.05) and a higher

Discussion

The data from this study present several novel findings on outcomes of IHCA. First, adherence to ACLS protocols throughout an event is correlated with increased ROSC in the setting of cardiac arrest. Previous studies have shown the importance of time to first defibrillation as being correlated with outcomes.7, 8 However, to our knowledge, adherence to published ACLS protocols throughout the entire resuscitation event has not been previously reported. Wayne et al. have previously shown that

Conclusions

In conclusion, our results demonstrate that adherence to ACLS protocols throughout an event is associated with increased ROSC in the setting of IHCA. Furthermore, the results illustrate that both commissions of wrong actions and omissions of indicated actions are associated with decreased ROSC after such an event. Additionally, poor adherence to protocols by ACLS-certified personnel suggests that significant opportunities still exist for improving retention of knowledge regarding ACLS

Conflict of interest statement

None of the authors have any financial or personal relationships that could have any influence on this research or this manuscript.

IRB information

MUSC IRB II – HR#17810.

The requirement for written informed consent was waived by the Institutional Review Board.

Previous presentation

This report was previously presented, in part, at the ASA 2009

Acknowledgements

Foundation for Anesthesia Education and Research (FAER), Research in Education Grant (PI: McEvoy) provided funded research time. FAER was not involved in the study design or data analysis.

South Carolina Clinical & Translational Research Institute, Medical University of South Carolina's CTSA, supported by National Institutes of Health/National Center for Research Resources Grant Numbers UL1TR000062/UL1RR029882 provided biostatistical resources.

References (12)

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