BehindTheMedspeak: 'You're better off having your [cardiac] arrest at Nordstrom'

That's the bottom flat line of a study published today in the New England Journal of Medicine on the slow response time to in-hospital cardiac arrests.

Dr. Leslie A. Saxon (chief of cardiology at the University of Southern California and author of an editorial accompanying the study), speaking on her cellphone, told New York Times reporter Denise Grady, "You're better off having your arrest at Nordstrom, where I'm standing right now, because there are 15 people around me."

You could look it up — or just read the Times front page story, which follows, here.

Hospitals Slow in Heart Cases, Research Finds

In nearly a third of cases of sudden cardiac arrest in the hospital, the staff takes too long to respond, increasing the risk of brain damage and death, a new study finds.

Researchers estimate that the delays contribute to thousands of deaths a year in the United States.

The study was based on 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 patients survived long enough to be discharged from the hospital, as opposed to 39.3 percent when the shock was given on time.



The study, being published Thursday in The New England Journal of Medicine, is the largest ever to look at what happened to patients with “shockable” abnormalities in heart rhythm, and to correlate their outcomes with the time it took to deliver the needed shock.

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.

Being black also increased the odds of a delay, but the researchers said this finding probably reflected the quality of hospitals in areas where most blacks live and are treated, rather than a decision by medical workers to drag their feet because of a patient’s race.

In hospitals as a whole, delays may be even more frequent than is suggested by the 30 percent figure in the hospitals studied, said the lead author, Dr. Paul S. Chan of St. Luke’s Mid America Heart Institute in Kansas City, Mo., and the University of Michigan. Dr. Chan said that because all the hospitals in the study had joined a national registry on cardiac arrest, meaning that they were already putting special efforts into trying to meet resuscitation guidelines, they probably performed better than average.

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

Dr. Leslie A. Saxon, chief of cardiology at the University of Southern California and author of an editorial accompanying the study, said most people probably assumed that a hospital would be the best place to have a cardiac arrest. But, Dr. Saxon 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 and try to solve it.

“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.

While exact numbers are not known, researchers estimate that 370,000 to 750,000 hospitalized patients have a cardiac arrest and undergo resuscitation every year in the United States. In a third to 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.)

“We know what works, what saves lives,” Dr. Chan said. “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 at night and on weekends, not enough personnel are available. In some hospitals, nurses other than those in 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,” Dr. Chan said, “the only doctor may be in the emergency room.”



The next step in the research, he said, is to learn precisely what successful hospitals do that sets them apart, so that others can learn. Hospitals with the best track records may keep their staffs sharp, he said, by conducting resuscitation drills or “mock codes,” and may have rapid response teams, which are specially trained groups that take care of all cardiac arrests.

Dr. Chan said another factor was the type and the amount of resuscitation equipment available. Traditional defibrillators used in hospitals require that a doctor or a 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 last decade or so are meant to be used by laymen: 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, making it impossible to harm someone by firing off an unnecessary shock. But so far they have not been used much in the care of hospitalized patients.

Dr. Saxon said the automatic defibrillators should be used more, along with the type of heart monitoring now given mostly to cardiac patients. Not everyone needs such monitoring, she said, but it may be in order for those who are very ill with kidney problems, diabetes or pneumonia, even if they have no 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.”

Now, she said, if a patient is not being monitored, and is in the hospital on the weekend in a unit that has one nurse for every four to eight patients, a cardiac arrest could go unnoticed for too long.

Speaking on her cellphone, Dr. Saxon said, “You’re better off having your arrest at Nordstrom, where I’m standing right now, because there are 15 people around me.”

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Here's the abstract of the New England Journal article.

Delayed Time to Defibrillation after In-Hospital Cardiac Arrest

Background: Expert guidelines advocate defibrillation within 2 minutes after an in-hospital cardiac arrest caused by ventricular arrhythmia. However, empirical data on the prevalence of delayed defibrillation in the United States and its effect on survival are limited.

Methods: We identified 6789 patients who had cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia at 369 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. Using multivariable logistic regression, we identified characteristics associated with delayed defibrillation. We then examined the association between delayed defibrillation (more than 2 minutes) and survival to discharge after adjusting for differences in patient and hospital characteristics.

Results: The overall median time to defibrillation was 1 minute (interquartile range, <1 to 3 minutes); delayed defibrillation occurred in 2045 patients (30.1%). Characteristics associated with delayed defibrillation included black race, noncardiac admitting diagnosis, and occurrence of cardiac arrest at a hospital with fewer than 250 beds, in an unmonitored hospital unit, and during after-hours periods (5 p.m. to 8 a.m. or weekends). Delayed defibrillation was associated with a significantly lower probability of surviving to hospital discharge (22.2%, vs. 39.3% when defibrillation was not delayed; adjusted odds ratio, 0.48; 95% confidence interval, 0.42 to 0.54; P<0.001). In addition, a graded association was seen between increasing time to defibrillation and lower rates of survival to hospital discharge for each minute of delay (P for trend <0.001).

Conclusions: Delayed defibrillation is common and is associated with lower rates of survival after in-hospital cardiac arrest.