Care of cardiac and non ‐ cardiac patients Niall Herity MD Consultant Cardiologist Clinical Director (Cardiology)
General caveats • Highly selected population (~ 3 per 1000) • Retrospective analysis • Generally in the setting of good medical and nursing care
Survival trends after in hospital cardiac arrest
Cardiac versus non ‐ cardiac patients who have in ‐ hospital cardiac arrest
In ‐ hospital cardiorespiratory arrest Location CCU Medical and surgical wards Hypoxia Myocardial Pathology ischaemia Acidosis Arrhythmia Usually VF/VT Usually PEA or asystole Treatment Defibrillation CPR and adrenaline Survival Commoner Rare
What did we learn? • No systematic decision about CPR status on admission nor on subsequent consultant review • Evidence of physiological deterioration and lack of escalation mechanisms
CPR status
Death
Death and culture
Recommendation “CPR status must be considered and recorded for all acute admissions, ideally during the initial admission process and definitely at the first consultant review...”
CPR decisions at first review An 88 year old lady is admitted from home with dyspnoea. She has a history of metastatic colonic carcinoma with lung secondaries. Treatment is started with oxygen and antibiotics • Would you make a CPR decision? • What would it be? • Who would you discuss it with?
CPR decisions at first review A 45 year old man is admitted from home with chest pain. He was previously fit and well. A diagnosis of acute coronary syndrome is made and appropriate treatment is commenced • Would you make a CPR decision? • What would it be? • Who would you discuss it with?
CPR decisions at first review A 38 year old lady is admitted from home with chest pain. She has a history of breast carcinoma with bony secondaries. She has 2 young children aged 8 and 10 • Would you make a CPR decision? • What would it be? • Who would you discuss it with?
CPR decisions at first review • 88 • 38 • Dyspnoea • Chest pain • Metastatic colonic • Metastatic breast carcinoma with lung carcinoma with bony secondaries secondaries
Why are doctors reluctant to make DNACPR decisions?
“Playing God” “The elderly, disabled, confused ‐ those who are least able to form a rapport with doctors ‐ become an intolerable burden on an over ‐ stretched health system Before long, a consultant will make the decision to withdraw treatment in their 'best interests‘ The decision is actually based on an assessment of the patient's quality of life versus the potential resource consumption. Unfortunately, the assessment is rarely either detailed or objective. Doctors are so busy and tired that they make subjective decisions influenced by their own culture, upbringing and opinions. These decisions are often unknown to relatives”
Sense of failure
Complaint or litigation
Personal publicity
Peer criticism or the GMC
Early warning systems and escalation
Barriers to escalation of care Medical or surgical patients with physiological warning signs Escalation attempt Professional barriers HDU/ICU
Removing the barriers Medical or surgical patients with physiological warning signs Protocol ‐ led escalation Transfer of responsibility New management HDU/ICU/CCU Palliative or or plan in same place
Can anything be learned from cardiology?
How do we manage our sickest patients? High risk conditions: 999 Myocardial infarction Pulmonary embolism Low risk Ill † ED Pneumonia COPD Sepsis GI bleeding Lo Medical or Acute surgical Ill † w surgical ward Stroke risk Metabolic conditions • Nurses and junior doctors • Limited interventions • Under ‐ appreciation of physiological deterioration • Avoidable cardiorespiratory arrest
ST elevation MI 999 Low risk Ill † ED 24/7/365 Cardiac catheterisation laboratory • Senior doctors and nurses (with trainees) • Extensive, immediate, expert and definitive intervention • Recognition of physiological deterioration • (Unavoidable cardiorespiratory arrest)
Why not all the others? Acute GI bleeding surgical COPD Stroke 999 24/7/365 Low risk Ill ED GI +/ ‐ Surgical +/ ‐ Respiratory CT scanner endoscopy theatre +/ ‐ HDU +/ ‐ lysis • Senior doctors and nurses (with trainees) • Extensive, immediate, expert and definitive interventions • Recognition of physiological deterioration • (Unavoidable cardiorespiratory arrest)
Summary • CPR decisions on admission and first consultant review: change in culture required • Automatic inpatient escalation services • Pre ‐ hospital identification of the highest risk groups and bypass some traditional structures
Conclusion “The real problem isn’t how to stop bad doctors from harming, even killing their patients. It’s how to stop good doctors from doing so” Atul Gawande The New Yorker, February 1999
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