Acute Crit Care.  2021 May;36(2):109-117. 10.4266/acc.2020.01095.

Analysis of avoidable cardiopulmonary resuscitation incidents with a part-time rapid response system in place

• Cho JY
• Lee DS
• Choi YY
• Park JS
• Cho YJ
• Yoon HI
• Lee JH
• Lee CT
• Lee YJ

• KMID: 2516258
• DOI: http://doi.org/10.4266/acc.2020.01095

Abstract

Background
Although a rapid response system (RRS) can reduce the incidence of cardiopulmonary resuscitation (CPR) in general wards, avoidable CPR cases still occur. This study aimed to investigate the incidence and causes of avoidable CPR.
Methods
We retrospectively reviewed the medical records of all adult patients who received CPR between April 2013 and March 2016 (35 months) at a tertiary teaching hospital where a part-time RRS was introduced in October 2012. Four experts reviewed all of the CPR cases and determined whether each event was avoidable.
Results
A total of 192 CPR cases were identified, and the incidence of CPR was 0.190 per 1,000 patient admissions. Of these, 56 (29.2%) were considered potentially avoidable, with the most common cause being doctor error (n=32, 57.1%), followed by delayed do-not-resuscitate (DNR) placement (n=12, 21.4%) and procedural complications (n=5, 8.9%). The percentage of avoidable CPR was significantly lower in the RRS operating time group than in the RRS non-operating time group (20.7% vs. 35.5%; P=0.026). Among 44 avoidable CPR events (excluding cases related to DNR issues), the rapid response team intervened in only three cases (6.8%), and most of the avoidable CPR cases (65.9%) occurred during the non-operating time.
Conclusions
A significant number of avoidable CPR events occurred with a well-functioning, part-time RRS in place. However, RRS operation does appear to lower the occurrence of avoidable CPR. Thus, it is necessary to extend RRS operation time and modify RRS activation criteria. Moreover, policy and cultural changes are needed prior to implementing a full-time RRS.

Keyword

cardiopulmonary resuscitation; hospital rapid response team; prevention

Figure

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  Figure 1. Distribution of cardiopulmonary resuscitation (CPR) cases according to rapid response system monitoring and operating times.

Reference

1. Hijazi MH, Sinno M. The rapid response team reduces the number of cardiopulmonary arrests and hospital mortality. Chest. 2009; 136:13S.

2. Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Böttiger BW, et al. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation. 2008; 79:350–79.

3. Nolan JP, Soar J, Smith GB, Gwinnutt C, Parrott F, Power S, et al. Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Resuscitation. 2014; 85:987–92.

4. Chon GR, Lee J, Shin Y, Huh JW, Lim CM, Koh Y, et al. Clinical outcomes of witnessed and monitored cases of in-hospital cardiac arrest in the general ward of a university hospital in Korea. Respir Care. 2013; 58:1937–44.

5. Hodgetts TJ, Kenward G, Vlackonikolis I, Payne S, Castle N, Crouch R, et al. Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital. Resuscitation. 2002; 54:115–23.

6. Peberdy MA, Cretikos M, Abella BS, DeVita M, Goldhill D, Kloeck W, et al. Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement: a scientific statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian Resuscitation Council, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, and the New Zealand Resuscitation Council); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiopulmonary, Perioperative, and Critical Care; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation. 2007; 116:2481–500.

7. Jones D, Bellomo R, DeVita MA. Effectiveness of the medical emergency team: the importance of dose. Crit Care. 2009; 13:313.

8. Jones D, Bellomo R, Bates S, Warrillow S, Goldsmith D, Hart G, et al. Long term effect of a medical emergency team on cardiac arrests in a teaching hospital. Crit Care. 2005; 9:R808–15.

9. Dacey MJ, Mirza ER, Wilcox V, Doherty M, Mello J, Boyer A, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med. 2007; 35:2076–82.

10. Galhotra S, DeVita MA, Simmons RL, Dew MA; Members of the Medical Emergency Response Improvement Team (MERIT) Committee. Mature rapid response system and potentially avoidable cardiopulmonary arrests in hospital. Qual Saf Health Care. 2007; 16:260–5.

11. Kim Y, Lee DS, Min H, Choi YY, Lee EY, Song I, et al. Effectiveness analysis of a part-time rapid response system during operation versus nonoperation. Crit Care Med. 2017; 45:e592–9.

12. Perkins GD, Jacobs IG, Nadkarni VM, Berg RA, Bhanji F, Biarent D, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein resuscitation registry templates for out-of-hospital cardiac arrest: a statement for healthcare professionals from a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Resuscitation. 2015; 96:328–40.

13. Bedell SE, Deitz DC, Leeman D, Delbanco TL. Incidence and characteristics of preventable iatrogenic cardiac arrests. JAMA. 1991; 265:2815–20.

14. Williamson RA, Phillips-Bute BG, McDonagh DL, Gray MC, Zomorodi AR, Olson DM, et al. Predictors of extraventricular drain-associated bacterial ventriculitis. J Crit Care. 2014; 29:77–82.

15. Churpek MM, Yuen TC, Park SY, Meltzer DO, Hall JB, Edelson DP. Derivation of a cardiac arrest prediction model using ward vital signs. Crit Care Med. 2012; 40:2102–8.

16. Kathiresan B, Quinnell T, Slack K. P304 complications related to tracheostomy tube change: evaluation of practice. Thorax. 2014; 69:A207–8.

17. Rassias AJ, Ball PA, Corwin HL. A prospective study of tracheopulmonary complications associated with the placement of narrow-bore enteral feeding tubes. Crit Care. 1998; 2:25–8.

18. Larkin GL, Copes WS, Nathanson BH, Kaye W. Pre-resuscitation factors associated with mortality in 49,130 cases of inhospital cardiac arrest: a report from the National Registry for Cardiopulmonary Resuscitation. Resuscitation. 2010; 81:302–11.

19. Al-Qahtani S, Al-Dorzi HM, Tamim HM, Hussain S, Fong L, Taher S, et al. Impact of an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality. Crit Care Med. 2013; 41:506–17.

20. Kenward G, Castle N, Hodgetts T, Shaikh L. Evaluation of a medical emergency team one year after implementation. Resuscitation. 2004; 61:257–63.

21. Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ. 2002; 324:387–90.