Original Article
Unsuccessful Emergency Medical Resuscitation — Are Continued Efforts in the Emergency Department Justified?
N Engl J Med 1991; 325:1393-1398November 14, 1991
- Abstract
- Abstract
Background.
The majority of attempts to resuscitate victims of prehospital cardiopulmonary arrest are unsuccessful, and patients are frequently transported to the emergency department for further resuscitation efforts. We evaluated the efficacy and costs of continued hospital resuscitation for patients in whom resuscitation efforts outside the hospital have failed.
Methods.
We reviewed the records of 185 patients presenting to our emergency department after an initially unsuccessful, but ongoing, resuscitation for a prehospital arrest (cardiac, respiratory, or both) by an emergency medical team. Prehospital and hospital characteristics of treatment for the arrest were identified, and the patients' outcomes in the emergency room were ascertained. The hospital course and the hospital costs for the patients who were revived were determined.
Results.
Over a 19-month period, only 16 of the 185 patients (9 percent) were successfully resuscitated in the emergency department and admitted to the hospital. A shorter duration of prehospital resuscitation was the only characteristic of the resuscitation associated with an improved outcome in the emergency department. No patient survived until hospital discharge, and all but one were comatose throughout hospitalization. The mean stay in the hospital was 12.6 days (range, 1 to 132), with an average of 2.3 days (range, 1 to 11) in an intensive care unit. The total hospital cost for the 16 patients admitted was $180,908 (range per patient, $1,984 to $95,144).
Conclusions.
In general, continued resuscitation efforts in the emergency department for victims of cardiopulmonary arrest in whom prehospital resuscitation has failed are not worthwhile, and they consume precious institutional and economic resources without gain. (N Engl J Med 1991;325:1393–8.)
Media in This Article
Table 1
Characteristics of Patients and Outcomes in the Emergency Department.Table 2
Characteristics of Attempts at Resuscitation and Outcomes in the Emergency Department.Article Activity
- Article
CARDIOPULMONARY resuscitation has been implemented extensively in hospitals throughout the United States in the 30 years since its inception.1 Originally used for victims of acute but reversible insult,2 its application has grown to include attempts to resuscitate some patients in whom the prognosis is extremely poor. Studies have demonstrated that the usefulness of resuscitation in hospitalized patients is limited, especially in elderly persons3 4 5 and in patients with renal failure,3 , 6 pneumonia,6 cancer,4 , 6 or sepsis.4 Recognizing that sometimes it is more appropriate to withhold this therapy from certain patients, most U.S. hospitals have adopted do-not-resuscitate policies to preempt efforts at resuscitation in hospitalized patients with a poor prognosis.
In addition to the widespread use of in-hospital resuscitation, emergency medical systems have been implemented throughout the United States to deliver care rapidly when arrests occur outside the hospital. The majority of such arrests result from cardiac events, usually ventricular fibrillation, in patients with coronary artery disease.7 8 9 Several factors have been shown to improve outcome in cardiac arrests occurring outside the hospital: the presence of witnesses,10 , 11 the administration of cardiopulmonary resuscitation by a bystander,11 12 13 14 15 16 17 18 an initial cardiac rhythm of ventricular tachycardia or fibrillation,13 , 14 , 17 , 19 and early defibrillation.12 13 14 15 , 19 , 20 In the Seattle area, where an extensive, tiered response system is in place and lay education in techniques of cardiopulmonary resuscitation has been emphasized, the overall rates of survival until hospital discharge of patients with cardiac arrest occurring outside the hospital and due to ventricular fibrillation have reached approximately 30 percent.14
Although much is known about the outcomes in patients who have cardiac arrests in the inpatient and outpatient settings, little information is available about the relation between the two systems in the case of patients who have arrests outside the hospital, who undergo unsuccessful attempts at resuscitation by the emergency medical system, and who are then transported to the hospital for continued, and usually more extensive, resuscitation. To assess the efficacy and cost effectiveness of this practice, we reviewed the case histories of 185 patients with such arrests who lacked vital signs when they were transported to our emergency department by ambulance.
Methods
Rhode Island Hospital is a 719-bed university teaching hospital located in Providence, the state's largest city. It functions as a community hospital for the greater Providence area and serves as the principal tertiary care referral center and designated trauma center for patients in southeastern New England.
A review of the patient logs of the Rhode Island Hospital emergency department between October 1, 1985, and June 30, 1987, identified patients for inclusion in this study. Only patients who came to the emergency department by ambulance without spontaneous pulse or respirations (i.e., without vital signs) after an arrest outside the hospital and in whom initial resuscitative efforts were unsuccessful but ongoing were included for analysis. Patients were excluded from the study if their arrests were due to trauma or drowning or if they were under 16 years old. All other patients were included, regardless of the primary cause of their arrests (e.g., cardiac, respiratory, or resulting from an overdose).
In the state of Rhode Island, it is standard for resuscitation to be initiated by the emergency medical system in all patients found without a pulse, regardless of their initial cardiac rhythm, except patients in whom prolonged arrest is evident (i.e., cases of rigor mortis). Once begun, resuscitation is continued until the emergency medical unit transfers the care of the patient to the staff of the emergency department. In the case of emergency medical units capable of advanced cardiac life support,21 full and aggressive implementation of the cardiac-arrest protocol is undertaken at the scene, with subsequent transport to the emergency department only after these initial attempts at resuscitation. Alternatively, in basic cardiac life-support units,22 immediate transport of the patient is the primary directive.
One hundred eighty-five patients met the criteria for entry into the study. Prehospital resuscitation factors were ascertained, including an estimate of the time from the arrest to the arrival of the ambulance, the initial cardiac rhythm recorded by the ambulance personnel, and the extent of resuscitative efforts in the field — either basic cardiac life support, defined as resuscitation limited to chest compression and assisted ventilation, or advanced cardiac life support, defined as the basic treatments plus defibrillation, intravenous medication, and esophageal obturator airway or endotracheal intubation. The time required for resuscitation (both at the scene and during transport to the emergency department) was noted, and the distance traveled by the emergency medical unit was estimated on the basis of the patient's township of origin. Accounts of witnessed as compared with unwitnessed arrests and of the initiation of cardiopulmonary resuscitation by bystanders could not be obtained reliably in a majority of cases and are not included in our data.
All patients presenting to the emergency department received resuscitation according to the advanced cardiac life-support protocol,21 including chest compression, intubation, the use of vasopressors and antiarrhythmic agents, direct-current cardioversion, the placement of a central venous catheter or pacemaker, and pericardiocentesis, as deemed necessary by the attending physician. The emergency department records of those cases were reviewed, and the patient's outcome (death or resuscitation) was determined. Demographic data were recorded, including age, sex, race, and previous medical history. Information was obtained about resuscitation efforts in the emergency department, such as the time of admission, the duration of resuscitation (to the pronouncement of death or the first evidence of a pulse), cumulative recorded nursing time, cardiac rhythm on arrival in the emergency department, arterial blood gas levels, and serum potassium levels. The cumulative time spent by physicians was estimated, with the assumption that at least two physicians were present for the duration of the resuscitation or longer. The cause of the arrest was determined from the circumstances surrounding the event or from postmortem examination, if available.
In the case of patients who were successfully revived in the emergency department and admitted to the hospital, information on their subsequent course was gathered from a review of hospital charts. Information about the following was obtained: hospital outcome (death or survival until discharge), neurologic status at the time of death or discharge, time in the intensive care unit and total duration of hospital stay, in-hospital cause of death, and outpatient course.
The costs of hospitalization for the patients admitted to the hospital were estimated from the charges accrued in the various departments (i.e., pharmacy, laboratory, radiology, and the like) and the charges related to the patients' stay in the intensive care unit and elsewhere in the hospital, as well as the cost of any procedures they may have undergone. Once these figures were determined, cost-to-charge ratios for each department were used to calculate the total hospital cost for each patient. These figures were then adjusted to reflect 1991 dollars. Professional fees were not included in cost determinations.
To assess differences between the characteristics of survivors and those of the patients who died, a statistical analysis using the chi-square test (or Fisher's exact test, as appropriate) for categorical variables or Student's t-test (unpaired and two-tailed) for continuous data was performed.
Results
Characteristics of Patients and Resuscitations
During the 21-month study period, a total of 185 patients who lacked vital signs were brought to the emergency department for further care after an arrest outside the hospital with initially unsuccessful, but continuing, resuscitation by the emergency medical system. The mean (±SD) age was 67±15 years. Patients who died of other than cardiac causes (16 of 185, or 9 percent) tended to be younger than the other patients (mean age, 47±21 vs. 68±13 years, P<0.01), and most had respiratory arrests. One hundred twenty-three patients (66 percent) were men, and 148 (80 percent) were white. Most of the patients (94 percent) were ambulatory at the time of their arrest. Coronary artery disease was the most common preexisting medical condition reported (in 34 percent), followed by congestive heart failure (16 percent), hypertension (15 percent), and diabetes mellitus (15 percent).
Most of the emergency medical units arrived at the scene of the arrest (61 of 82, or 74 percent) within five minutes of receiving the call for help. Approximately two thirds of all the patients (114 of 185, or 62 percent) received advanced cardiac life support from the responding emergency medical unit, and one third of all patients (68 of 185, or 37 percent) had defibrillation according to protocol for ventricular tachycardia or ventricular fibrillation. The initial cardiac rhythm that the emergency medical units reported finding most often at the scene was ventricular tachycardia or ventricular fibrillation, seen in 60 percent (68 of 114) of the electrocardiographically monitored patients (i.e., those treated by emergency medical units capable of advanced cardiac life support). For the same group of patients, however, ventricular tachycardia and ventricular fibrillation represented only 32 percent (36 of 114) of the rhythms seen in the emergency department.
The cases were divided into tertiles — <5, 5 to 8, and >8 km (<3, 3 to 5, and >5 miles) — according to the distance traveled by the emergency medical units from the scene of the arrest to the emergency department. The time required for the initial resuscitation and transport of the patient to the emergency department was more than 15 minutes in two thirds of the cases (128 of 185, or 69 percent).
The mean resuscitation time in the emergency department was 22.4 minutes, and the cumulative nursing time averaged 116 minutes. The estimated time spent by physicians during these resuscitation efforts was 45 minutes.
Outcomes
Sixteen patients (9 percent) were successfully resuscitated in the emergency department and admitted to the hospital (Table 1Table 1
Characteristics of Patients and Outcomes in the Emergency Department.). There were no significant differences in age, race, or cause of arrest between these surviving patients and those who died. There was, however, a significant predominance of women among the survivors, and this finding was independent of age and cause of arrest. Improved survival was also noted in patients who had a history of congestive heart failure.The shorter the distance from the scene of the arrest to the hospital (i.e., the more urban the setting), the more likely the patient was to receive advanced cardiac life support from the responding emergency medical unit (P = 0.0001 for distances ≤8 km [5 miles] vs. >8 km). However, the extent of resuscitation by emergency-medical-system personnel (advanced cardiac life support vs. basic cardiac life support) did not affeet survival in the emergency department, and there was no association between the use of defibrillation and hospital admission (Table 2Table 2
Characteristics of Attempts at Resuscitation and Outcomes in the Emergency Department.). Although ventricular tachycardia and ventricular fibrillation constituted the majority of the rhythms noted by the emergency medical units at the scene of the arrest, there was a significant decline in their prevalence in the emergency department. There were no differences, however, in survival in the emergency department according to cardiac rhythm, in either the field or the emergency department. Improved survival in the emergency department was observed when less than 15 minutes was required for initial emergency-medical-system field resuscitation and transport to the emergency department; this improvement was independent of the extent of emergency-medical-system resuscitation. Although differences in the time it took for the emergency medical unit to arrive at the scene did not result in a statistically significant difference in emergency department outcome, it should be noted that no patient was revived with subsequent resuscitative efforts when it took more than 10 minutes for the emergency medical unit to arrive. Similarly, when the distance traveled by the emergency medical unit from the scene to the emergency department was more than 8 km, there was a decline in survival in the emergency department, albeit not a statistically significant one.Analysis of the duration of resuscitation in the emergency department for each group revealed that it did not predict survival. The cumulative nursing time was not statistically compared in the two groups; significant differences would have been expected because of the additional time needed to prepare the survivors for admission and transport to their inpatient beds, and not necessarily by any intrinsic differences between the groups.
Hospital Course and Medical Costs in Resuscitated Patients
Of the 16 patients admitted to the hospital after successful resuscitation in the emergency department, none lived to be discharged. The mean stay was 12.6 days (range, 1 to 132), with an average stay in the intensive care unit of 2.3 days (range, 1 to 11). Only one of the patients resuscitated regained consciousness (but remained intubated) before her death on the first hospital day; the others were comatose until death. One patient's prehospital arrest was due to a subarachnoid hemorrhage, whereas the remainder had apparently primary cardiac events. In about half the patients, the cause of hospital death was refractory hypotension (in 7 of 16 patients, or 44 percent); recurrent arrhythmias (in 5 of 16 patients, or 31 percent) and neurologic causes (in 4 of 16 patients, or 25 percent), including the discontinuation of life-support measures (e.g., ventilation and dialysis) after persistent coma, accounted for the rest of the deaths. The total cost of hospitalization for these 16 patients was $180,908, with an average cost per patient of $11,307 (range, $1,984 to $95,144).
Discussion
This study was undertaken to evaluate the outcomes and costs of continued hospital resuscitation in patients after a cardiac or respiratory arrest outside the hospital, when initial efforts at resuscitation proved unsuccessful. With approximately 350,00021 cardiac arrests in the United States every year, at least two thirds of which take place outside hospital settings,9 there are undoubtedly many patients similar to those we studied. Patients who had other forms of arrest, including but not limited to victims of hypothermia, trauma, and drowning, were excluded from this study.
We believe that the care given to our patients by the emergency medical system and the emergency department and the resulting outcomes are representative of those in many urban and suburban centers. During the period of our study, a review of the records from 3 emergency medical, services that contributed more than half the patients to this study (in which 25 services participated) disclosed that the rate of successful resuscitation by the emergency medical system after cardiopulmonary arrest was approximately 20 percent. A telephone survey of emergency medical systems in major New England cities revealed similar success rates, ranging from 12 to 20 percent. A retrospective design was chosen, because a prospective study might have influenced the length and intensity of hospital resuscitation and perhaps the outcome in the emergency department.
Of the patients transported to our emergency department after an unsuccessful attempt at resuscitation, only 9 percent were revived by further efforts and admitted. No patient lived to be discharged from the hospital, however, and all but one were comatose at the time of death, having had profound and irreversible anoxia and brain injury as a result of prolonged arrest. For the average patient, the total time spent undergoing resuscitation efforts before reaching the hospital and being treated in the emergency department was more than 35 minutes. Although the mean stay was just over 12 days, one comatose patient lived for more than 4 months before dying. The poor outcomes and lack of survival in the hospital in these patients who have undergone prolonged resuscitation are not surprising, since studies of survival after cardiac arrest occurring either in the hospital or before the patient reaches it have established that for an arrest to last more than 12 to 15 minutes is an independent predictor of death.4 , 17
Subgroup analysis of the patients who survived resuscitation efforts in the emergency department has limited value because all patients died before discharge, but two features of this group are worth noting. First, the predominant cardiac rhythms noted in the field were ventricular tachycardia and ventricular fibrillation, whereas electromechanical dissociation and asystole were the primary rhythms noted in the emergency department. These data, along with those of previous studies,14 , 23 suggest that electromechanical dissociation and asystole represent terminal rhythms, probably the result of the deterioration, with prolonged arrest, of the ventricular tachycardia or ventricular fibrillation that had precipitated the event. More important, for both the patients who had an arrest in the hospital and those with a prehospital arrest, dramatic differences in the rates of successful outcome have been demonstrated to be associated with cardiac rhythm, with only occasional survival noted once electromechanical dissociation or asystole is present.3 , 4 , 14 , 16 , 24 Second, the only characteristic of treatment by the emergency medical system that was predictive of improved outcome in the emergency department was a total resuscitation time of less than 15 minutes — confirmation of the ineffectiveness of prolonged resuscitation.
Previous studies of unsuccessful resuscitation in medical patients before they reach the hospital have also documented extremely poor outcomes. In a review of the records of 281 consecutive patients arriving in the emergency department after failed attempts at resuscitation by the emergency medical system, Kellermann et al.25 reported that only 4 patients survived until hospital discharge. Two who were reported to be neurologically intact had their arrests shortly before their arrival in the emergency department, whereas the other two required nursing home care because of severe neurologic deficits. The results of our study also closely parallel what has been observed in both pediatric patients and trauma patients — populations in which the causes of arrest are largely non-cardiac. In a review by Shimazu and Shatney26 of 267 trauma patients without vital signs who were treated in the emergency department, only 2.6 percent survived and only 1.5 percent were considered functional. The results were just as grim when O'Rourke27 reviewed 34 pediatric patients brought to the emergency department with apnea and without a pulse; 7 (21 percent) survived, but all were discharged to a chronic care facility, and most were in a persistent vegetative state.
Our study raises important questions about the need for continued resuscitative measures and their advisability once patients reach the hospital, given our observations of the apparent futility of such efforts and their consumption of health care resources. For all the patients we studied, cumulative nursing time in the emergency department averaged almost 2 hours, and estimated physicians' time approximately 45 minutes. The patients who survived to be admitted to the hospital had a mean stay in the intensive care unit of more than two days and a mean hospital stay of almost two weeks, and they required complete care until their deaths. This represented a considerable allocation of beds in the intensive care unit and elsewhere in the hospital, equipment, respiratory therapy, and nursing and physicians' time, all of which are scarce commodities. Given the uniformly fatal outcome, it is difficult to justify the use of the facilities and personnel required for this care.
Furthermore, these efforts resulted in a cost to the hospital of $180,908 for the 16 patients surviving until hospital admission. Additional costs, conservatively estimated at between $100,000 and $150,000, were incurred for the 169 patients who underwent unsuccessful attempts at resuscitation in the emergency department. When one considers the magnitude of the problem presented by sudden death in this country and the fact that our data represent only one hospital's experience, the implication is that there are considerable nationwide outlays for seemingly little benefit, and perhaps at the expense of more productive practices.
Provided that expert advanced cardiac life support is administered before the patient reaches the hospital, it seems reasonable to establish emergency-medical-system protocols to stop prolonged, unsuccessful resuscitation at the scene, perhaps after consultation with the physician in the emergency department, and this concept should be supported by appropriate legislation in all states. This would eliminate much of the current need to use the resources of the emergency department to treat these patients. In addition, the members of the emergency department team should temper their efforts when a patient arrives after undergoing prolonged resuscitation, since such patients have as dire an outlook as any identifiable group of patients who have had an arrest. Several authors and commissions have proposed28 29 30 31 32 that the physician is under no obligation to perform procedures when there is little or no expectation of medical benefit, and this population of patients certainly has little hope of meaningful recovery as a result of continued resuscitative efforts.
An occasional patient who has had an arrest outside the hospital can be resuscitated successfully in the emergency department. Physicians caring for these hospitalized patients can advise relatives about the prognosis and considerations for further therapy and resuscitation on the basis of the uniformly poor outcomes noted in this study, as well as the individual patient's condition at the time of admission.
In a broader context, emphasis should be placed on prehospital care for the patient with cardiopulmonary arrest, since it is clear that patients treated in this setting have the greatest chance of successful resuscitation. Specifically, measures should be taken to increase the number and responsiveness of emergency medical units capable of defibrillation, performed either by trained paramedics or with automatic external defibrillators (for which efficacy at lower cost has been demonstrated even with minimally trained personnel),33 and to provide widespread instruction for lay people in techniques of cardiopulmonary resuscitation, since these are the two modifiable determinants of survival. Many experts have strongly endorsed these proposals in the past to improve the outcome after an arrest occurring outside the hospital,12 13 14 15 , 17 , 20 , 34 35 36 but their recommendations take on even greater importance given the lack of survival after subsequent attempts at resuscitation in the emergency department, since the only real opportunity to rescue such patients appears to be in the field.
We are indebted to Mrs. Dawn Oliveira and Mrs. Arlene Grant for assistance in the preparation of the manuscript and to Patricia O'Sullivan, Ph.D., for assistance with the statistical analysis.
Source Information
From the Division of Cardiology, Rhode Island Hospital, and the Brown University Program in Medicine, Providence, R.I. (W.A.G., A.S.M.), and the Division of Cardiology, University of Rochester Medical Center, Rochester, N.Y. (R.J.C.). Address reprint requests to Dr. Gray at the Division of Cardiology, Rhode Island Hospital, 593 Eddy St., Providence, RI 02903.
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