Validation of a clinical decision aid to discontinue in-hospital cardiac arrest resuscitations.

CONTEXT: Most patients undergoing in-hospital cardiac resuscitation do not survive to hospital discharge. In a previous study, we developed a clinical decision aid for identifying all patients undergoing resuscitation who survived to hospital discharge. OBJECTIVE: To validate our previously derived clinical decision aid. DESIGN, SETTING, AND PARTICIPANTS: Data from a large registry of in-hospital resuscitations at a community teaching hospital in Georgia were analyzed to determine whether patients would be predicted to survive to hospital discharge (ie, whether their arrest was witnessed or their initial cardiac rhythm was either ventricular tachycardia or ventricular fibrillation or they regained a pulse during the first 10 minutes of chest compressions). Data from 2181 in-hospital cardiac resuscitation attempts in 1987-1996 involving 1884 pulseless patients were analyzed. MAIN OUTCOME MEASURE: Comparison of predictions based on the decision aid with whether patients were actually discharged alive from the hospital. RESULTS: For 327 resuscitations (15.0%), the patient survived to hospital discharge. For 324 of these resuscitations, the patients were predicted to survive to hospital discharge (sensitivity = 99.1%, 95% confidence interval, 97.1%-99.8%). In 269 resuscitations, patients did not satisfy the decision aid and were predicted to have no chance of being discharged from the hospital. Only 3 of these patients (1.1%) were discharged from the hospital (negative predictive value = 98.9%), none of whom were able to live independently following discharge from the hospital. CONCLUSION: This decision aid can be used to help physicians identify patients who are extremely unlikely to benefit from continued resuscitative efforts.

Resuscitation in the hospital: relationship of year and rhythm to outcome.

OBJECTIVE: determine the frequency of initial rhythms in in-hospital resuscitation and examine its relationship to survival. Assess changes in outcome over time. METHODS: retrospective cohort (registry) including all admissions to the Medical Center of Central Georgia in which a resuscitation was attempted between 1 January, 1987 and 31 December, 1996. RESULTS: the registry includes 3327 admissions in which 3926 resuscitations were attempted. Only the first event is reported. There were 961 hospital survivors. Survival increased from 24.2% in 1987 to 33.4% in 1996 (chi(2)=39.0, df=1, P<0.0001). Survival was affected strongly by initial rhythm (chi(2)=420.0, df=1, P<0.0001) and decreased from 63.2% for supraventricular tachycardia (SVT) to 55.3% for ventricular tachycardia (VT), 51.0% for perfusing rhythms (PER), 34.8% for ventricular fibrillation (VF), 14.3% for pulseless electrical activity (PEA) and 10.0% for asystole (ASYS). PEA was the most frequent rhythm (1180 cases) followed by perfusing (963), asystole (580), VF (459), VT (94) and SVT (38). DISCUSSION: the powerful effect of initial rhythm on survival has been reported in pre-hospital and in-hospital resuscitation. VF is considered the dominant rhythm and generally accounts for the most survivors. We report good outcome for each; however, VF represents only 13.8% of events and 16.7% of survivors. PEA accounts for more survivors (169) than does VF (160). Our improved outcome is partially explained by changes in rhythms, but other institutional variables need to be identified to fully explain the results. Further studies are needed to see if our findings can be sustained or replicated.

In-hospital resuscitation: association between ACLS training and survival to discharge.

CONTEXT: No data have been published on the relationship between advanced cardiac life support (ACLS) training of the individual who initiates resuscitation efforts and survival to discharge. OBJECTIVE: To determine whether patients whose arrests were discovered by nurses trained in ACLS had survival rates different from those discovered by nurses not trained in ACLS. DESIGN: Cohort case-comparison. SETTING: A 550-bed, tertiary care center in central Georgia. SUBJECTS: Patients whose cardiopulmonary arrest was discovered by a nurse who activated the in-hospital resuscitation mechanism. MAIN OUTCOME MEASURE: Patient survival to discharge. RESULTS: Initial rhythm was strongly related to survival to discharge and individually associated with 57% of the variability in survival. Nurse's training in advanced cardiac life support was also strongly related to survival and individually associated with 29% of the variability. Combining both the variables determined 62% of the variability in survival to discharge. Patients discovered by an ACLS-trained nurse (n=88) were about four times more likely to survive (33 survivors, 38%) than were patients, discovered by a nurse without training in ACLS (n=29, three survivors, 10%). CONCLUSION: Arrest discovery by nurses trained in ACLS is significantly and dramatically associated with higher survival-to-discharge rates.

Students together against negative decisions (STAND): evaluation of a school-based sexual risk reduction intervention in the rural south.

Twenty-one 10th graders selected as opinion leaders by their peers in a rural county in a southern state participated in a 36-hour peer-educator training program Students Together Against Negative Decisions (STAND) based on diffusion of innovations theory and the transtheoretical model. Comparison subjects received either a 22-hour leadership training course (n = 20) or no intervention (n = 45). STAND and comparison subjects completed a 154-item written knowledge, attitude, and behavior survey at the beginning of the training (Time 1), at the end of the training (Time 2), and again 8 months later (Time 3). One hundred and sixty-seven other 9th and 10th graders in the intervention county and 74 in the comparison county completed an abbreviated telephone interview at Time 1 and Time 3. At Time 3 STAND-trained peer educators reported significantly greater increases in AIDS Risk Behavior Knowledge (more than 4 times comparison groups), frequency of conversations with peers about birth control/condoms (+180% vs. +12%) and sexually transmitted diseases (STDs; +282% vs. -33%), condom use self efficacy (+16% vs. -1%), and consistent condom use (+28% vs. +15%). STAND teens also reported substantial favorable trends at Time 3, including increased condom use (+213% vs. +31%) and decreased unprotected intercourse (-30% vs. +29%). At Time 3 teens in the intervention county reported significantly greater increases in the number of people who talked with friends in the preceding 3 months about STDs (+39% vs. -19%) or with a parent/adult about sex (+6% vs. -37%). Intervention county teens also reported a substantial but nonsignificant 2.6-fold greater increase in condom use at last intercourse (+64% vs. +25%) but unfavorable changes in other risk behaviors. The STAND peer-educator training program appears to be an effective method for improving selected sexual knowledge, attitudes, and behaviors among participant teenagers in the rural South.

Resuscitation in the hospital: differential relationships between age and survival across rhythms.

OBJECTIVE: Assess the frequency and outcome of inhospital resuscitation and determine the relationship between patient age and survival and whether it is affected by initial rhythm. DESIGN: Retrospective, single-institution, registry study of inhospital resuscitation. SETTING: A 550-bed, tertiary-care, teaching hospital in Macon, GA. PATIENTS: All admissions for which a resuscitation was attempted in the Medical Center of Central Georgia during the period of January 1, 1987 through December 31, 1993. The registry sample included 2,394 admissions, for which 2,813 resuscitation attempts were made; only the first resuscitation attempt during an admission was analyzed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Rates of survival to discharge steadily increased from 24.4% in 1987 to 38.6% in 1993; the overall survival rate was 26.8%. Age, used as a continuous variable, was strongly related to survival (odds ratio = 0.984; p < .0001). Categorically, overall survival rates for pediatric, adult, and geriatric patients were 56.4%, 29.0%, and 24.0%, respectively. Survival rates also varied significantly (odds ratio = 0.469; p < .0001) among initial rhythms, i.e., supraventricular tachycardia (60.7%), ventricular tachycardia (57.6%), perfusing rhythms (49.84%), ventricular fibrillation (32.0%), pulseless electrical activity (14.6%), and asystole (9.1%). The relationship between age and survival did not change across the years included in the study, but did vary as a function of initial rhythm (p < .0001). Age was positively related to survival when initial rhythm was supraventricular tachycardia (p = .04), negatively related to survival when the initial rhythm was perfusing (p < .0001) or pulseless electrical activity (p = .0002), and not related to survival when the initial rhythm was ventricular tachycardia (p = .98), ventricular fibrillation (p = .14), or asystole (p = .21). CONCLUSIONS: The relationship between patient age and a successful resuscitation attempt is not as simple as reported earlier. Whether age is related to increased or decreased survival, or is unrelated to survival, depends on the rhythm extant when resuscitation attempts begin. Survival rates were higher than most reported elsewhere and improved significantly over time. Multicentered studies are needed to determine whether these results are unique to the institution studied.

Arteriographic incidence of coronary artery disease in black men with chest pain.

To determine the incidence of arteriographically proven coronary artery disease in black men evaluated for chest pain, we retrospectively reviewed the charts of 208 black men, aged 20 to 60, who had coronary arteriography at the Medical Center of Central Georgia (MCCG) from 1985 through January 1990. Age, type of chest pain, and risk factors commonly accepted as associated with coronary disease (hypertension, family history, left ventricular hypertrophy, diabetes, smoking, and hypercholesterolemia) were identified for each patient. Patients were categorized by previous evidence of coronary disease: 145 were studied to evaluate suspected disease and 63 to evaluate previously proven (prior catheterization) or presumptive (prior myocardial infarction) disease. Chest pain groups (typical and atypical angina) were analyzed by Pearson chi-square goodness of fit using the Diamond and Forrester age and chest pain tables as a model. Risk factors were analyzed using a maximum likelihood chi-square test. Coronary artery disease was common in the study group (48.6% of all patients) but significantly less than predicted by the Diamond and Forrester tables. Risk factors were highly prevalent, but only age and smoking were associated with catheterization-proven coronary artery disease in this group. We conclude that coronary artery disease is common in black men evaluated for chest pain but less frequent than would be expected from comparison with findings in white men presenting similar clinical features. Risk factors other than age and smoking were not associated with increased incidence of disease. A prospective study is needed to delineate a more effective means of evaluating black male patients with chest pain.